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REMINDER: BCBSNC Policy on Third-Party or Servicing Provider Ordering of Diagnostic Services

Blue Cross and Blue Shield of North Carolina's (BCBSNC) Diagnostic Imaging Management (DIM) Program was initiated in February 2007 to encourage the use of appropriate diagnostic imaging services at the appropriate time and in the appropriate order. Communication to BCBSNC's provider network has included language indicating that the ordering provider must contact American Imaging Management (AIM) to request authorization for the DIM service and that the servicing provider cannot request the authorization. There are two exceptions to this policy:

  1. If the ordering provider (PCP, specialist) has diagnostic imaging equipment in his/her office and will be filing the claim for the technical component (or billing globally) for the DIM service;
    or
  2. The servicing provider is an interventional radiologist, as established by BCBSNC's Credentialing Department.

The reasoning behind this policy is that only the ordering, or referring, provider will have sufficient clinical data on the patient to provide to AIM for a medical necessity determination. Servicing providers such as hospitals or freestanding radiology practices are not likely to have seen the patient and are therefore not the most appropriate source of clinical data such as patient medical history, symptoms and/or diagnoses.

As such, it is a violation of BCBSNC's policies for:

  1. A servicing location to market or offer to BCBSNC referring providers its services in obtaining the authorization from AIM on behalf of the referring provider; or
  2. A referring provider to allow the servicing location to contact AIM on their behalf to request the authorization for DIM services.

This policy is referenced in Section 8.9 of the BCBSNC Provider eManual and is therefore incorporated by reference into BCBSNC's provider agreements. See https://www.bcbsnc.com/assets/providers/public/pdfs/BlueBook-July2010.pdf for details.