Radiology program

Our radiology program promotes the use of advanced diagnostic imaging services based on widely accepted clinical judgment.

Our commitment to our members means we're ensuring they receive appropriate care and the best health care experience, while we continue to be responsible stewards of the cost of health care. We have partnered with Carelon Medical Benefits Management (Carelon) to administer our radiology program, which has two components:

  1. Radiology Quality Initiative (RQI) - Ordering/referring non-radiological physicians, other health care professionals and/or their trained staff must contact Carelon to obtain an order number before scheduling an elective outpatient diagnostic imaging procedure.
    If an order number is not obtained through Carelon prior to the imaging procedure being performed, the procedure will be considered a provider write-off and cannot be billed to the member.
  2. Advanced Imaging Authorization - We provide full utilization management (UM) to review for medical necessity for our members. As part of our advanced imaging authorization review:

  • If Carelon determines the service does not meet medical necessity criteria, the requested service/procedure will be denied and an order number will not be provided.
  • If an imaging provider performs the service/procedure without an approved order number, the procedure will be considered a provider write-off and cannot be billed to the member.

Use the tabs below to learn more about our radiology program.

Included services

Obtain an order number

CPT code list

View codes that require notification in the radiology section of our Pre-authorization Lists.

The goals of this program are to:

  • Curtail the performance of inappropriate advanced diagnostic imaging studies
  • Advocate bio-safety issues, including reduction of unnecessary radiation exposure
  • Promote the selection of the most clinically appropriate diagnostic imaging services based on a patient's clinical needs
  • Encourage standardization of medical practice patterns and reduce variation in clinical evaluation through provider education and collaboration
  • Enhance quality of health care for diagnostic imaging studies using evidence-based medicine and outcomes research from numerous resources

Diagnostic imaging services included in this program

The following services are included in the program when they are performed in an outpatient, elective setting:

  • Nuclear cardiology
  • Nuclear medicine imaging
  • Positron emission tomography (PET) studies
  • Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA)
  • Computerized tomography (CT)/computerized tomography angiography (CTA)
  • Stress echocardiography (SE)/resting transthoracic echocardiography (TTE)/transesophageal echocardiography (TEE)

View a complete list of codes that are included in this program on our pre-authorization lists.

Note: A procedure being done for mapping and planning for surgery requires an order number from Carelon.

Diagnostic imaging services excluded from this program

Order numbers are not required for services performed at the following locations:

  • Hospital observation
  • Inpatient hospitalization
  • Emergency room (ER) visits
  • Contracted urgent care centers
  • Outpatient surgery (hospital or free-standing surgery centers)

The following diagnostic imaging services are excluded from the program but still require pre-authorization:

  • Virtual colonoscopy
  • Magnetic resonance spectroscopy (MRS)
  • Coronary computerized tomography angiography (CCTA)

CPT codes

View codes that require notification in the radiology section of our pre-authorization lists.

Learn more

Program requirements

Program requirements

Our contracted providers are required to participate in all quality improvement initiatives and programs as indicated in their provider agreements.

Ordering/referring providers

Ordering/referring non-radiological physicians, other health care professionals and/or their trained staff must contact Carelon to obtain an order number before scheduling an elective outpatient diagnostic imaging procedure for any member who participates in this program.

Note: Non-radiology specialists are required to request an order number for outpatient elective advanced imaging services regardless of their affiliation with a facility or practice.

Servicing providers

Prior to performing an imaging service covered under the program, it is critical that servicing providers confirm an order number has been obtained. Review all CPT codes on your Carelon order to confirm the services listed are the ones your facility will provide to the patient. If the services differ from what is listed on the order number, follow up with the ordering physician's office immediately or within two business days after a test is performed. If the services rendered are coded differently than what is authorized on the order number, the services may be denied.

You can confirm an order by calling Carelon or checking the ProviderPortal. If an order number has not been obtained, servicing providers should request that the ordering provider contact Carelon to obtain one.

Hospital-based servicing providers

Hospital-based imaging providers are strongly encouraged to verify that an order number has been obtained prior to scheduling the procedure.

  • Inpatient diagnostic imaging is not included in this program.
  • Hospital-based radiologists who only provide professional services are not required to request an order number.
  • Non-radiology specialists will be required to request an order number for outpatient elective advanced imaging services regardless of their affiliation with a facility or practice.
  • If a patient is seen in an emergency room (ER) and the ER physician refers the patient to return to the hospital at a later date for advanced radiology services through the hospital's outpatient service, an order number must be obtained from Carelon.

Urgent care services and the need for an order number

  • If the patient is referred by an urgent care provider to the ER for advanced diagnostic imaging services, an order number from Carelon is not needed.
  • If a patient is referred by an urgent care provider to a free-standing imaging center or the hospital's outpatient service department for advanced diagnostic imaging services, an order number from Carelon is needed.

Obtaining retrospective order number no longer accepted

We do not accept retrospective requests for an order number for any reason. Emergency room services do not require an order number. Outpatient elective diagnostic imaging services are typically non-urgent in nature and an order number can be obtained through Carelon's ProviderPortal or by contacting Carelon's call center at 1 (877) 291-0509.

Program design and criteria

Program design and criteria

Carelon is a leading imaging management company with national experience working with health plans and providers to promote the most appropriate use of advanced diagnostic imaging services. This promotion is done using widely accepted clinical content and advanced analytical capabilities.

Criteria review

What happens if the criteria for the imaging services are not met?

If all medical necessity criteria are not met or additional information or review is needed, the case will be forwarded to a registered nurse (RN) who will use additional clinical experience and knowledge to evaluate the request against clinical guidelines.

If the RN reviewer still does not believe the service meets the criteria, the case will be forwarded to an Carelon physician reviewer, who will contact the ordering provider directly to discuss the case and diagnostic imaging guidelines prior to issuing the order number.

Carelon's diagnostic imaging utilization management program guidelines serve as a foundation for this discussion.

The physician reviewer can approve the case based on evaluation of information collected or through his or her discussion with the ordering physician or other health care professional. If the Carelon physician reviewer cannot approve the case based on the information previously collected, is unable to reach the ordering provider to discuss the case, or is unable to approve the case based on the information supplied by the ordering provider during the peer-to-peer discussion an order number will not be issued.

How can I check on the status of a request that was not approved at intake?

Users can check on the status of a request forwarded for additional clinical review by:

  • Checking Carelon's ProviderPortal
  • Calling Carelon Customer Service at 1 (877) 291-0509

If my request requires a peer-to-peer discussion with a physician reviewer can a member of my nursing staff handle this?

Yes. In the event that a request is transferred to an Carelon physician reviewer for a peer-to-peer discussion, a member of the nursing staff may contact Carelon to discuss the case on behalf of the ordering provider.

Can our patients contact Carelon?

Health plan members should contact our Customer Service if they have any questions about our radiology program or their benefits. The phone number is listed on the back of the member ID cards.

Criteria development

Who develops the clinical criteria for the program?

Carelon's guidelines for appropriate diagnostic imaging utilization have been reviewed and approved by the National Committee for Quality Assurance (NCQA) and the American Accreditation HealthCare Commission (URAC) and are reviewed annually by:

  • Client medical directors
  • Physician review panels
  • Local imaging advisory councils (representing local physician communities)
  • An independent physician review board, including cardiologists, orthopedic surgeons, radiologists, neurologists and neurosurgeons

View and download Carelon's clinical guidelines.

What methods and resources are used in development of Carelon's clinical practice guidelines?

Development of Carelon's diagnostic imaging utilization management guidelines involves integration of medical information from multiple sources to support the use of high-quality and state-of-the-art diagnostic imaging services. The process for criteria development is based on technology assessment, peer-reviewed medical literature, clinical outcomes research and consensus opinion in medical practice.

The primary resources used for Carelon's guideline development include:

  • American Cancer Society
  • National Guideline Clearinghouse
  • American Heart Association (AHA)
  • Society of Nuclear Medicine (SNM)
  • American Academy of Pediatrics (AAP)
  • American Academy of Neurology (AAN)
  • Society of Interventional Radiology (SIR)
  • Centers for Medicare & Medicaid Services (CMS)
  • American Institute of Ultrasound in Medicine (AIUM)
  • Agency for Healthcare Research and Quality (AHRQ)
  • American College of Radiology (ACR) appropriateness criteria
  • American College of Cardiology (ACC) appropriateness criteria
Program members

Members who participate in this program

The radiology program applies to all members residing in Washington state.

Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

Administrative services only (ASO) groups may decide to purchase the Advanced Imaging Authorization component as a benefit during their annual renewal period. The renewal period can vary by month, depending on the group. It is therefore important to check electronic authorization tool on the Availity Portal to determine if a patient's plan has changed.

Request an order number

Request an order number

Carelon offers two methods to easily submit imaging order requests, allowing provider offices to complete imaging order requests in less than five minutes.

  • Online: ProviderPortal is available 24 hours a day, seven days a week. Online tools assist with managing radiology cases, such as checking the status of open requests, canceling requests and changing servicing providers.
    • Using the online ProviderPortal is the preferred option for many offices. It is quicker than calling and allows you to easily view and print your assigned order number.
  • Phone: Contact Carelon's call center at 1 (877) 291-0509 to submit order number requests.

Note: Ordering physicians (those referring the member for an imaging procedure) and servicing providers (those free-standing or hospital facilities that perform imaging procedures) may submit order requests.

Information required when requesting an order number

Ordering/referring provider offices will need to provide the following information when requesting an order number:

  • Diagnosis
  • Symptoms
  • Exam type
  • Imaging provider
  • Treatment/clinical history
  • Patient and ordering physician information

Use our Order Entry Tip Sheet (PDF) as a helpful guide.

If the information provided meets Carelon's clinical criteria and is consistent with our medical policy, the ordering/referring provider office will be asked to select the provider who will perform the imaging study. An order number will then be issued.

Order numbers are valid for 60 days after the date of issue. If the study is not scheduled within this 60-day period, the ordering/referring provider office should contact Carelon for an extension. Carelon will then provide a new order number.

Note: An order number is not a guarantee of claim payment. The claim will be processed in accordance with the terms of a member's health care benefit plan. The order number does not need to be included on your submitted claim.

Carelon's ProviderPortal help desk

Carelon offers a dedicated web help desk for ProviderPortal users. Representatives are trained to assist with such problems as:

  • Data issues
  • System outages
  • Navigation issues
  • Resetting passwords

Contact the Carelon Help Desk at 1 (877) 291-0509. At the prompt, select the plan name.

Register with Carelon

Registration is easy via the ProviderPortal by Carelon. Once you register, you'll receive a password within 24 hours. If you are already registered with Carelon for another health plan, you do not need to re-register; just go to Manage My Groups and choose the tab Add a health plan.