Insurance
Insurance Authorization & Pre-Authorization
While we make every effort to know the referral and pre-authorization requirements of the insurance plans we are contracted with, it is our recommendation that you contact your insurance plan when trying to confirm your plan requirements. Please check your insurance identification card for the telephone number to call.
Insurance Participation
Fairfax Radiological Consultants, P.C. participates with all major insurer's in the Northern Virginia/Washington Metropolitan area and provides full insurance billing and claim resolution. If you have insurance, you will only receive a bill from us if your insurance company denies payment or you have a co-payment or deductible due.
* Click on the insurance company name below ( i.e. AETNA ) to view additional information including selected locations (if indicated), pre-certification requirements and a link to the providers web site.
AETNA
| Product Type |
Precertification Requirements |
| HMO/PPO/Medicare |
HMO/POS/Medicare Golden :
(note: may reflect Medicare PPO on card)
MRI/MRA, CT, Nuc. Med., Nuc. Cardiology (MUGA), PET. |
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PPO : Effective 5/1/07, precert required by some employer groups for CTs, MRs, NucMed/Card (MUGA), PET - must call CareCore/Aetna to determine if precert required. Please ensure MR Breast is medically necessary per Aetna policy. |
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Medicare Open Plan : follows all Medicare guidelines/policies |
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website |
Alliance PPO/One Net PPO
| Product Type |
Precertification Requirements |
| PPO |
For GEHA/APWU/Amerihealth : MRI/MRA, CT, and Nuc. Cardiology (MUGA), PET; possibility for Thyroid and Breast Biopsies. |
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For Guardian Alliance : Thyroid & Breast Biopsies, possibility for PET. |
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All others vary by Patient's benefits. |
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website |
* Amerigroup Selected locations only
| Product Type |
Precertification Requirements |
| Medicaid - Commercial Managed Care |
Insurance participation with Amerigroup is contracted only for services at Inova owned sites (MRI Center, PET Imaging Center, Inova Loudoun-Dulles South, or Inova Loudoun-Leesburg). PreCert may be required for CT, MR, Nuc Card and PET. |
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website |
Anthem BlueCross BlueShield of VA & HealthKeepers and HealthKeepers Plus/Famis
| Product Type |
Precertification Requirements |
| HMO/POS/PPO/Indemnity/Medicaid (note: Medicaid precert requirements are consistent with the HMO requirements) |
HMO/POS(HealthKeepers and HealthKeepers Plus/Famis)/PPO/Indemnity : PET, MR and CT (excluding Medicare Supplement, ITS Host, Dept. of Corrections), Thyroid and Breast Biopsy Stereo U/S guided (for HMO, if ID# begins with '1' or 'YTH'), DEXA (all HMO; for some out-of-state plans for non-HMO), OB Sono after 2 visits (HMO); precertification possibly required for Nuc. Med./Card. Please ensure MR Breast is medically necessary per Anthem policy. |
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website |
CareFirst BlueCross BlueShield and BlueChoice
| Product Type |
Precertification Requirements |
| HMO/POS/PPO/Indemnity |
HMO/POS - BlueChoice : Precertification required if services rendered at an Inova Facility. |
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PPO/Indemnity : MR, PET and CT precertification possible for out-of-state plans. Please ensure MR Breast is medically necessary per CareFirst policy. |
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website |
Champus/Tricare Standard
| Product Type |
Precertification Requirements |
| PPO |
No Precert Required; Confirm medical necessity for MRs and CTs -- waiver needed if not medically necessary and patient still wishes to obtain exam. |
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website |
* Champus/Tricare Prime Selected locations only
| Product Type |
Precertification Requirements |
| HMO |
Insurance participation with Champus/TricarePrime is contracted only for services at Inova owned sites (MRI Center, PET Imaging Center, Inova Loudoun-Dulles South, or Inova Loudoun-Leesburg). PreCert may be required for CT, MR, Nuc Card and PET. |
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website |
CIGNA HealthCare
| Product Type |
Precertification Requirements |
| HMO/POS/PPO/Indemnity |
HMO/POS/Open Access Plus : MR, CT, Nuc. Cardiology (MUGA), and PET. |
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PPO/Indemnity/EPO/PPA : Verify precert requirements on the back of the patient's ID card or on the CIGNA web site. |
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website |
First Health/(CCN)
| Product Type |
Precertification Requirements |
| PPO |
Depends on patient's benefits. |
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website |
Great West/One Health
| Product Type |
Precertification Requirements |
| PPO |
Precert required for: MR, CT, and PET. |
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website |
Humana
| Product Type |
Precertification Requirements |
| Medicare - Gold Choice or Advantage Plans |
Waiver and Precert requirements are consistent with Medicare CMS. |
| Group Health & Individual Plans |
FRC is NON-PARTICIPATING. We do not participate with NON-MEDICARE Humana products and the patient will be expected to sign a waiver and pay at the time of service.
|
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website |
KAISER
| Product Type |
Precertification Requirements |
| HMO/POS (Kaiser Added Choice) |
HMO : Kaiser insurance referral number required for MR, Nuc Med/Card, Interventional, PET and Experimental/Investigational exams (e.g. CTAs, Virtual Colonoscopy, etc.) |
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POS : Reduced benefits without Kaiser referral where required. |
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Precert required for: MR, CT, and PET. |
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website |
MAMSI (MDIPA/OptimumChoice/MLH)
| Product Type |
Precertification Requirements |
| HMO: MDIPA, Optimum Choice |
HMO/POS : Insurance cards that do not have the word 'Direct' on the card must reflect RAD=NOVA, PAR or "no-designation" for non-MR Services in order to use a N.VA. radiologist. This does not apply to Mamsi Life and Health (MLH). |
| POS: MDIPA Preferred, Optimum Choice, Preferred. |
HMO/POS : precertification for brain PET, specified musculoskeletal MR studies, pelvic MRI and scrotal sono for infertility. All other MRs require PCP referral. |
| PPO/Indemnity: MAMSI Life & Health |
Effective 3/17/08: the restriction of no more than 1 US OB covered unless diagnosis is one of United's complicated diagnosis codes is terminated. There is no restriction of how many OB sonograms a patient can have if ordered by a physician. |
| PPO: Alliance (reference above) |
Effective 5/15/06 : Precert Requirements for CT (including chest and coronary CTA) and other MR procedures -- Please reference MAMSI's precertification form. |
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website |
Medicaid - VA
| Product Type |
Precertification Requirements |
| Government Plan |
MR, CT, Nuc. Med., Nuc. Card., PET. |
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Note: FRC does not participate with Amerigroup Medicaid - Authorization required for all services. |
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website |
Medicare/Highmark
| Product Type |
Precertification Requirements |
| Government Plan |
MR, CT, Nuc. Med., Nuc. Card., PET. |
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Note: FRC does not participate with Amerigroup Medicaid - Authorization required for all services. |
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website |
NCPPO (WellPoint, Unicare)
| Product Type |
Precertification Requirements |
| PPO |
Effective DOS 6/18/07 for Unicare only : Precert Required for CT/CTA, MR, Nuc Card, and PET. |
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website |
OneNet PPO
| Product Type |
Precertification Requirements |
| PPO |
Please reference Alliance PPO. |
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website |
PHCS
| Product Type |
Precertification Requirements |
| PPO/POS |
Depends on patient's benefits. |
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website |
UNITED HealthCare (Non-MAMSI Products)
| Product Type |
Precertification Requirements |
| HMO/POS/PPO |
Effective 3/17/08: the restriction of no more than 1 US OB covered unless diagnosis is one of United's complicated diagnosis codes is terminated. There is no restriction of how many OB sonograms a patient can have if ordered by a physician. |
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For dates of service on and after 5/7/07 - FRC must have a referring physician notification # from United in order to provide the following service(s) for Choice and Select benefit plans unless otherwise informed by United: CT, MR, PET, NucMed/Card. |
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website |
