The 1199SEIU Benefit Fund maintains updated radiology requirements to ensure that 1199SEIU patients are receiving the tests they need in the most appropriate setting. Please refer to the questions below for answers to some of the most commonly asked questions about this program.
Still have questions? Email [email protected] or call our Provider Hotline at (646) 473-7160.
What radiology procedures need to be pre-authorized? Who is responsible for requesting prior approval for MRIs, MRAs, CAT Scans and PET Scans? Is there an expiration date for a prior authorization? What is the Fund’s radiology privileging program? What if my specialty is not listed on the Privileging specialty list? Can any specialties provide all radiology services? If I have a dual specialty and one specialty is listed on the PrivilegingGuide and the other is not, can I provide radiology services under theapproved specialty? What will happen if I submit a claim for a radiology code that is not indicated for my specialty? Where should I refer my 1199SEIU patients if they need additional radiology services? What radiology procedures need to be pre-authorized?
You will need to request prior approval for MRIs, MRAs, PET scans and CAT scans by calling One Call Care Management (formerly Medfocus) at (888) 910-1199.
Who is responsible for requesting prior approval for MRIs, MRAs, CAT Scans and PET Scans?
The referring physician needs to call One Call Care Management (formerly Medfocus) at (888) 910-1199 to request an approval and must provide information regarding the patient’s diagnosis and the body part for the examination being requested.
Is there an expiration date for a prior authorization?
Yes. The prior authorization for the benefit determination is valid for 90 days from the date on the approval letter.
What is the Fund’s radiology privileging program?
The Fund’s privileging program ensures that credentialed providers are providing the appropriate radiology tests. To be reimbursed for radiology services to 1199SEIU patients, your specialty must be included on the Fund’s Privileging Specialty List.
What if my specialty is not listed on the Privileging Specialty List?
If your specialty is not listed on the Privileging Guide, you will not be reimbursed for any diagnostic radiology services in the 70000 cpt code series. Please refer your 1199SEIU patient to a radiologist or provider who is credentialed in one of these specialties. Click here to review the Privileging Guide.
Can any specialties provide all radiology services?
Only Radiology specialties can provide all radiology services.
If I have a dual specialty and one specialty is listed on the Privileging Guide and the other is not, can I provide radiology services under the approved specialty?
If you have two specialties, please make sure the Benefit Fund has credentialed and listed you under both specialties. Your claims will be processed based on the specialty(ies) the Fund has credentialed you for.
What will happen if I submit a claim for a radiology code that is not indicated for my specialty?
The claim will be denied and you may not balance bill members as outlined in your Provider Agreement.
Where should I refer my 1199SEIU patients if they need additional radiology services?
Please refer your patients to a One Call Care Management (formerly Medfocus) radiology provider. You can find a list of participating radiologists here.