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 : Precert required by some employer groups for CTs, MRs, NucMed/Card (MUGA), PET. 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
| Product Type |
Precertification Requirements |
| Medicaid - Commercial Managed Care |
All locations are par with Amerigroup. Precert required for MR, CT, PET, Nuc Card. Precert may be required for other procedures, specifically invasive procedures. |
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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 |
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. |
| |
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.
|
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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: Alliance |
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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website |
Medicare/Highmark
| Product Type |
Precertification Requirements |
| Government Plan |
website |
NCPPO (WellPoint, Unicare)
| Product Type |
Precertification Requirements |
| PPO |
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 |
Tricare (Northern Region) - Standard
| Product Type |
Precertification Requirements |
| PPO |
No referral or preauth required. Access www.hnfs.com or call 877/874-2273 for questions/verifying referral/preauth requirements
|
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website |
Tricare (Northern Region) - Prime
| Product Type |
Precertification Requirements |
| HMO - with PCM |
Referral required, preauth not required. Access www.hnfs.com or call 877/874-2273 for questions/verifying referral/preauth requirements
|
| HMO - with PCM but using POS or no PCM |
No referral or preauth required. Access www.hnfs.com or call 877/874-2273 for questions/verifying referral/preauth requirements
|
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website |
Tricare (Northern Region) - Secondary
| Product Type |
Precertification Requirements |
| n/a |
No referral or preauth required. Access www.hnfs.com or call 877/874-2273 for questions/verifying referral/preauth requirements
|
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website |
UNITED HealthCare (Non-MAMSI Products)
| Product Type |
Precertification Requirements |
| HMO/POS/PPO |
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 |
