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National Imaging Associates (NIA)

Buckeye Health Plan has contracted with National Imaging Associates Inc. (NIA) for radiology benefit management.

The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

Buckeye Health Plan oversees the NIA program and is responsible for claims adjudication. NIA manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.

Prior authorization is required for the following outpatient radiology procedures:

  • CT/CTA/CCTA
  • MRI/MRA
  • PET Scan

KEY PROVISION:

Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.

Go to the NIA website for more information.

Resources

Non-Emergent MSK Procedures

Effective January 1, 2024, Buckeye Health Plan is expanding our prior authorization program to include non-emergent MSK procedures. The expansion includes inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Buckeye Health Plan members.

We are partnering with National Imaging Associates, Inc (NIA)* for utilization management services for non-emergent, Medical Specialty Solutions. In consideration of the aforementioned agreement, Buckeye Health Plan will terminate its current MSK program and utilization management efforts with TurningPoint as of December 31, 2023.

Under the terms of the agreement between Buckeye Health Plan and NIA, Buckeye Health Plan will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. NIA will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with Buckeye Health Plan.

Providers may begin contacting NIA on January 1, 2024, to seek prior authorization for procedures scheduled on or after January 1, 2024.

FYI: Effective 1/1/2024 you will submit prior authorization requests to NIA for dates of service 1/1/2024 and forward. You can submit prior authorization requests up to 12/31/2023 to TurningPoint.  

MSK Program (PDF)

2024 Spine Surgery Utilization Review Matrix (PDF)

2024 Joint Surgery Utilization Review Matrix (PDF)

MSK Surgery - Hip-Knee-Shoulder-Lumbar-Cervical Program FAQs (PDF)

To obtain prior authorizations:

Medicaid: 1-800-642-6551

Medicare/MMP: 1-800-424-4158 

Ambetter from Buckeye (Exchange): 1-800-424-4915

How to file an NIA appeal 

Medicaid

Providers can request an appeal in writing or by calling the number below within sixty (60) days of the denial letter date.

Appeal rights include, the right to review the contents of the case file and to submit additional records or information. Appeals can be requested by writing or by calling us.

You can file an appeal by the following methods:

  • Phone: 1-866-972-9842 (must also send a written, signed appeal)
  • Fax: 1-888-656-0701
  • Letter via postal mail to:

National Imaging Associates, Inc.
Attn: Appeals Department
P.O. Box 1495
Maryland Heights, MO 63043

The written appeal should include the following information:

  • Provider name
  • Member number
  • Provider phone number
  • Why you think we should change the decision
  • Medical information to support the request

You will be notified of a decision:

  • Service not complete: within ten (10) calendar days of your appeal request.
  • Service complete: within thirty (30) calendar days of your appeal request.

Expedited Appeal:

If you believe that waiting up to 30 calendar days for a decision could seriously risk the patient’s life or health, including being able to reach, keep, or get back to maximum function, tell us when asking for an appeal. If we agree, we will make a decision within 72 hours of receiving the request. An expedited appeal may be filed orally. It does not have to be filed in writing.

 

Ambetter/Exchange

Providers can request an appeal in writing or by calling the number below within one hundred eighty (180) days of the denial letter date.

Appeal rights include, the right to review the contents of the case file and to submit additional records or information. Appeals can be requested by writing or by calling us.

You can file an appeal by the following methods:

  • Phone: 1-866-972-9842 (must also send a written, signed appeal)
  • Fax: 1-888-656-0701
  • Letter via postal mail to:

National Imaging Associates, Inc.
Attn: Appeals Department
P.O. Box 1495
Maryland Heights, MO 63043

The written appeal should include the following information:

  • Provider name
  • Member number
  • Provider phone number
  • Why you think we should change the decision
  • Medical information to support the request

You will be notified of a decision:

  • Service not complete: within thirty (30) calendar days of your appeal request.
  • Service complete: within sixty (60) calendar days of your appeal request.

Expedited Appeal:

If you believe that waiting up to 30 calendar days for a decision could seriously risk the patient’s life or health, including being able to reach, keep, or get back to maximum function, tell us when asking for an appeal. If we agree, we will make a decision within 72 hours of receiving the request. An expedited appeal may be filed orally. It does not have to be filed in writing.