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NIA to Manage Prior Authorizations for Non-Emergent MSK Services Beginning January 1, 2024

Date: 10/31/23

Fort Lauderdale, Florida

Beginning January 1, 2024, Sunshine Health, Ambetter from Sunshine Health, Children’s Medical Services (CMS) Health Plan and Wellcare are pleased to announce our expanded partnership with National Imaging Associates, Inc.1 (NIA), to provide utilization management services for the Musculoskeletal (MSK) Management program.

NIA will manage prior authorization for non-emergent inpatient and outpatient MSK.

Sunshine Health, Ambetter from Sunshine Health, CMS Health Plan and Wellcare will oversee the MSK program and continue to be responsible for claims adjudication and medical policies.

The following outlines the specific procedures requiring prior authorization from NIA. Providers may begin contacting NIA on January 1, 2024, to seek prior authorization for procedures scheduled on or after January 1, 2024.

MSK Surgeries: Prior authorization will be required for the following non-emergent inpatient and outpatient hip, knee, shoulder, lumbar and cervical surgeries:

Hip

  • Revision/Conversion Hip Arthroplasty
  • Total Hip Arthroplasty/Resurfacing
  • Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincer & labral repair)
  • Hip Surgery – Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)

Knee

  • Revision Knee Arthroplasty
  • Total Knee Arthroplasty (TKA)
  • Partial-Unicompartmental Knee Arthroplasty (UKA)
  • Knee Manipulation under Anesthesia (MUA)
  • Knee Meniscectomy/Meniscal Repair/Meniscal Transplant
  • Knee Surgery – Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)
  • Knee Ligament Reconstruction/Repair

Shoulder

  • Revision Shoulder Arthroplasty
  • Total/Reverse Shoulder Arthroplasty or Resurfacing
  • Partial Shoulder Arthroplasty/Hemiarthroplasty
  • Shoulder Rotator Cuff Repair
  • Shoulder Labral Repair
  • Frozen Shoulder Repair/Adhesive Capsulitis
  • Shoulder Surgery – Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

Lumbar

  • Lumbar Microdiscectomy
  • Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)
  • Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single & Multiple Levels
  • Sacroiliac Joint Fusion

Cervical

  • Cervical Anterior Decompression with Fusion –Single & Multiple Levels
  • Cervical Posterior Decompression with Fusion –Single & Multiple Levels
  • Cervical Posterior Decompression (without fusion)
  • Cervical Artificial Disc Replacement
  • Cervical Anterior Decompression (without fusion)

Key Provisions

  • It is the responsibility of the ordering physician to obtain prior authorization for all and MSK surgeries.
  • NIA does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room.
  • The ordering physician must obtain prior authorization with NIA prior to performing the surgery/procedure.
  • Facility admissions do not require a separate prior authorization. However, the facility should ensure that an NIA prior authorization has been obtained prior to scheduling the surgery/procedure.

Prior to the implementation date, you will be invited to attend a training webinar that will provide additional information. Should you have questions at this time, please contact Provider Services:

We appreciate your support and look forward to your assistance in assuring that members receive MSK services delivered in a quality, clinically appropriate fashion.

1Effective January 20, 2023, National Imaging Associates, Inc. is now a subsidiary of Evolent Health. Evolent Health and its affiliates and subsidiaries collectively referred to as “Evolent.”

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