QualityPath Benefit Details Procedure: CT or MRI

Providers:

View list of CT and MRI providers.

Notification requirements:

• Patients are strongly encouraged to notify The Alliance prior to the scan appointment. Go to www.qualitypath.com/tellus to submit your information. Notification is not required to receive QualityPath benefit levels for CTs and MRIs.

Services covered at QualityPath level of benefits:

• Services performed by the QualityPath provider during the patient medical service encounter, including but not limited to:
  • The CT or MRI and related services on a non-emergent, outpatient basis. The image must be the primary purpose for the encounter. (See the section “Triggering Service Codes” below for the list of eligible non-emergent outpatient CTs and MRIs.)
  • Drugs, biologicals, and radiopharmaceuticals that function as supplies and contrast agents and are administered by the QualityPath provider
  • All supplies
  • Ancillary services performed by the QualityPath provider
  • Guidance service
  • Image processing services
  • Observation services
  • Image reading and interpretation

Warranty:

Services under the warranty are covered under the QualityPath level of benefits. The warranty period begins the day of the scan and covers the following:

• Reimaging, due to image quality, of the same site of service Triggering Service Code within 30-days when both episodes are provided by the same QualityPath designated provider.

Patient requirements to maintain the warranty include:

• Receiving all reimaging from the QualityPath provider.
• Contact the patient experience manager at The Alliance at 800.223.4139 if your doctor asks for the scan to be redone because of the quality.

Exclusions:

The following services are not eligible for the QualityPath level of benefits. Check with your benefits administrator for coverage levels under the standard health plan benefits.

• Emergent or inpatient care
• When the image is performed as part of a surgical procedure or other more comprehensive service
• Certain Specialized Imaging—those that may require special equipment in addition to CT/MRI machine, including:
  • Breast MRI
  • Cardiac MRI
  • Cardiac CT
• All services provided by a non-QualityPath provider including but not limited to the administration of contrast materials.
• Services provided by a QualityPath provider performed prior to member’s enrollment in the program

Triggering Service Codes:

• Download CT and MRI trigger codes.