23-1295 Sign a Conservative Treatment Form for Advanced Imaging Authorizations
Date: 11/06/23
Make copies of the form linked below. Applies to Commercial HMO, PPO, EPO, POS, HSP and Ambetter HMO/PPO plans.
Starting on January 16, 2024, when requesting authorization for advanced imaging for members with the above plans, best practice for physicians and other providers is to submit a Conservative Treatment Form to National Imaging Associates Inc. (NIA). Submitting a completed form before services are authorized is considered a best practice for NIA approvals.
Health Net uses NIA for radiology benefit management. NIA determines medical necessity for advanced imaging and cardiac imaging procedures for fee-for-service (FFS) members.
Follow these steps
- Get the form. Download the form on the NIA website at Conservative Treatment Forms.
- Fill out and sign the form before ordering treatment.
- Submit the form by uploading it onto the NIA website or via fax. To fax, use the instructions on the NIA website.
How it works
The radiology benefit management 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.
Health Net oversees the NIA program and is responsible for claims adjudication.
For Commercial HMO, PPO, EPO, POS, HSP and Ambetter HMO/PPO, prior authorization is required for the following outpatient radiology procedures:
- CT/CTA/CCTA
- MPI
- MRI/MRA
- MUGA scan
- PET scan
How to submit a request to NIA
Submit prior authorization requests for FFS members to NIA online or by phone. NIA does not accept fax submissions.
Online: Post-login on NIA website.
Phone: 800-424-4802
Submit expedited authorization requests only by phone.
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. A separate prior authorization number is required for each procedure ordered.
Prior authorization is not required through NIA for services performed in the emergency department, on an inpatient basis or in conjunction with a surgery. Prior authorization and/or notification of admission in those instances is required through the Plan. To obtain authorization through NIA or for more information, visit NIA website.
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.
This information applies to Physicians.