Participating network physicians who perform or interpret ...


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Participating network physicians who perform or interpret ...

  1. 1. AUDIENCE: Participating network physicians who perform or interpret cardiac nuclear imaging tests SUBJECT: Change in reimbursement criteria for physicians providing and/or interpreting cardiac nuclear medicine imaging tests EFFECTIVE DATE: October 20, 2006 EMPIRE ADMINISTRATIVE CHANGE: Empire currently reimburses any participating network provider for providing and/or interpreting cardiac nuclear medicine imaging tests regardless of training or specialty certification. Empire has now established new criteria for reimbursement of participating providers for cardiac nuclear imaging studies,1 based on standards developed by the American College of Cardiology. Beginning October 20, 2006, only physicians meeting these new criteria will be eligible for reimbursement from Empire for the performance and/or interpretation of these tests. These new criteria will be reflected in an update to the Physician SourceBook. Providers registered with Empire in the following specialties will qualify for reimbursement:* • Cardiology • Pediatric cardiology • Nuclear cardiology • Nuclear medicine • Radiology • Radiology subspecialties Providers of specialties other than those listed above can also qualify for reimbursement by documenting completion of “Level 2” training in cardiac nuclear imaging. The following documentation must be provided: • Documentation of completion of “Level 2” training including four-six months of cardiology fellowship training, board certification in a cardiology specialty, nuclear medicine or radiology specialty. Certification must be with an institution with an accredited fellowship program. o Level 2 training includes 200 hours of radiation safety training, interpretation of 300 cases under direct supervision, including a minimum of 50 studies with direct hands-on experience and demonstration of competence in radiopharmaceutical preparation, administration of the dosage, setup of the gamma camera and the imaging computer, and computer analysis. • Documentation may take the form of a diploma or a letter from the director of the training program. You must be registered with Empire in one of the above-listed specialties or provide appropriate evidence of “Level 2” training by October 20, 2006. After October 20, 2006, if you are not registered in one of the above specialties, or have not provided documentation of completion of “Level 2” training, any claims you submit for cardiac nuclear medicine imaging testing will be denied. If a claim is denied because we have not received your documentation by October 20, 2006, you can request another claim review.
  2. 2. Simply resubmit your claim and be sure to include the date of your certification with your request. All requests for review must be received by us no later than 180 calendar days after the date of the adverse determination notice (denial). If your review request is not received within this required time frame, we will not review our prior denial determination. CONTACT: • You can submit training certification documents to: Empire, Attn: Correspondence, PO Box 1407, Church Street Station, New York, NY 10008-1407. Please be sure to include a copy of this letter with your documentation. • For more information, call Empire Provider Services at 1-800-992-BLUE (1-800-922-2583), Monday – Friday, 8:30 a.m. – 5:00 p.m. 1 Stewart, WJ, ACC/AHA Clinical Competence Statement on Echocardiography Task Force 4: Training in Echocardiography, American College of Cardiology, 1995. and Ritchie, J, ACC ACC/AHA Clinical Competence Statement on Nuclear Cardiology Task Force 5: Training in Nuclear Cardiology, American College of Cardiology, 1995. *Members are not liable for any amounts charged for covered services rendered by participating providers who do not meet the reimbursement criteria and cannot be balance billed. 4165 Nuc Med Prov Bull (7/06)