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Musculoskeletal program

For Prior Authorizations Submitted Prior to 10/01/2024

Carelon Musculoskeletal, Interventional Pain Management, Cardiology, and Radiology

Effective for dates of service on and after Oct. 1, 2024, Medica has partnered with Carelon, a utilization management (UM) program vendor, to support the provider submission and medical necessity review process for select musculoskeletal (MSK), cardiology, and radiology services. Submissions and review by Carelon will replace those previously managed by NIA Magellan. 

The following information applies to the NIA (Evolent) program, for dates of service on or prior to Sept. 30th 2024. Authorizations obtained through NIA (Evolent) will be available for viewing through 12/31/2024.

Medica works with National Imaging Associates (NIA) for review and authorization of our Musculoskeletal (MSK) Care Management Program. This includes prior authorization by the treating physician for non-emergent inpatient and outpatient musculoskeletal surgeries, specifically hip, knee, shoulder, lumbar, and cervical spine.

This program incorporates the following key components:

  • All Medica (formerly WellFirst Health) product lines will use the MSK Care Management Program.
  • MSK Care Management Program manages the medical necessity review for non-emergent inpatient and outpatient musculoskeletal surgeries through physician authorization, prior to performing the surgery.
  • Members who require the services of a provider who is not an in-network provider may require two authorizations. The initial authorization will need to be obtained for the use of the non-network provider via the Medica Utilization Management Department.
  • Authorization may be submitted through NIA's website RadMD.com or the NIA's toll-free phone number at 1-866-232-3955.
  • Musculoskeletal surgeries included in this program are non-emergent hip, knee, shoulder, lumbar, and cervical spine surgeries. A list of current spine surgery and knee, hip, and shoulder surgery CPT codes can be found in the Additional MSK resources section.

Only inpatient total knee arthroplasty and total hip arthroplasty will require prior authorization.

Knee

  • If a total knee arthroplasty (CPT Code 27447) is done in an outpatient hospital or ambulatory surgery setting, a prior authorization is NOT required.
  • All other outpatient hospital or ambulatory setting knee procedures require a prior authorization.
  • If the total knee arthroplasty (CPT Code 27447) is done as an inpatient, a prior authorization is required.

Hip

  • If a Total Hip Arthroplasty (CPT Code 27130) is done in an outpatient hospital or ambulatory surgery setting, a prior authorization is NOT required.
  • All other Outpatient Hospital or Ambulatory Setting hip procedures require a prior authorization.
  • If the total knee arthroplasty (CPT Code 27130) is done as an inpatient, a prior authorization is required.

Customer service

For questions, contact NIA's customer service representatives: 1-866-307-9729, available 7 a.m. - 7 p.m. CT, Monday - Friday.

Additional MSK resources