Blue Shield of California is contracted with National Imaging Associates, Inc. (NIA) to provide medical necessity reviews and prior authorization for Advanced Imaging, and Spine and Pain Management.
NIA reviews are not required for:
- Blue Shield HMO members (other than Direct Contract Network members), but authorization from the member's IPA or medical group may be needed
- Federal Employees Program (FEP) members
- Members covered by Blue Cross Blue Shield plans of other states
- Members covered by certain employer ASO plans
NOTE: Within 5 days before the actual date of service, providers MUST confirm with Blue Shield that the member's health plan coverage is still in effect.
Blue Shield reserves the right to revoke authorizations prior to services being rendered based on cancellation of the member's eligibility. Final determination of benefits will be made after review of the claim for limitations or exclusions.
The goal of this advanced imaging and spine and pain management program is to improve the quality, accountability, and cost of services to our members.
To accomplish this goal, NIA coordinates with referring providers to assure advanced imaging and spine and pain services are appropriate compared to national standard clinical protocols.
The following outpatient non-emergency advanced imaging examinations are reviewed by NIA:
- CT (computerized axial tomography), all examinations
- MRI (magnetic resonance imaging), all examinations
- MRA (magnetic resonance angiography), all examinations
- PET (positron emission tomography), all examinations
- Cardiac nuclear medicine studies (e.g., nuclear cardiac stress test)
- Outpatient and non-emergency inpatient lumbar and cervical spine surgery
- Outpatient interventional pain management
The following services are not reviewed by NIA:
- Hospital emergency room
- Inpatient advanced imaging services
- Observation bed
- Out of state services
- Outpatient surgery - incidental advanced imaging
Authorization requests and status information can be obtained by calling the NIA telephone call center. Authorization status for a provider's patients can also be checked online at the NIA website. The website also provides additional information about NIA and its services.