Payment Policies To date, the IAC is aware that the following insurers or companies (see index to the left) have adopted CT reimbursement directives. While the IAC attempts to stay abreast of reimbursement policies as a service to the CT community, these policies are changed and updated regularly by the insurance carriers. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. If you are aware of additional payment policies, or have questions about the information posted, please e-mail reimbursement@intersocietal.org.

PLEASE NOTE: The policy details within this document detailing accreditation requirements are referenced directly from insurer websites and manuals and are only a portion of the full reimbursement directives, please search for the full policy using the links provided.

Select a policy below to view the accreditation requirements (listed alphabetically):

Aetna Mid-America .................................... 2 Anthem BCBS (Virginia) .............................. 3 Anthem Blue Cross Medicare Advantage (CA, CT, IN, KY, ME, MO, OH, WI) ............... 4 Arkansas BlueCross BlueShield ................... 5 BlueCross BlueShield of Alabama ............... 6 BlueCross BlueShield of Georgia ................ 7 BlueCross BlueShield of Louisiana .............. 8 BlueCross Blue Shield of Massachusetts .... 9 BlueCross BlueShield of Mississippi .......... 10 BlueCross BlueShield of North Carolina ... 11 BlueCross BlueShield of South Carolina ... 12 California Senate Bill 1237 (Medical Radiation Safety Act) ................................ 13 eviCore Healthcare (National) .................. 14 Centers for Medicare and Medicaid Services (National).................................... 15 Empire BlueCross BlueShield (New York) . 16 Florida Blue .............................................. 17 Highmark (DE, PA, WV) ............................ 18 Horizon Blue Cross Blue Shield of New Jersey ........................................................ 19 Independence Blue Cross Group (Philadelphia and Southeastern PA) ......... 20 Minnesota House Bill 2276 ....................... 21 National Imaging Associates (NIA) (National) ................................................. 22 Regence BlueCross BlueShield (Utah, Oregon) & Blue Shield of Idaho (including select counties of Washington) ................ 23 TriWest Healthcare Alliance ..................... 24 UnitedHealthcare (National) .................... 25 UnitedHealthCare - Oxford Health Plans (CT, NJ, NY) ............................................... 26 Wellmark BCBS (Iowa, South Dakota) ...... 27

IAC Vascular Testing – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 2 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Aetna Mid-America (IA, IL, IN, KS, KY, MI, MN, MO, MT, ND, NE, OH, OK, SD, TX, WI, WY) REFERENCED FROM AETNA OFFICE MANUAL FOR HEALTH CARE PROFESSIONALS – MID-AMERICA SECTION (11/14) Radiology accreditation requirements Aetna has radiology accreditation requirements for our commercial and Medicare Advantage business. To be eligible for reimbursement for the technical part of advanced diagnostic imaging procedures, the following types of providers must be accredited by the American College of Radiology (ACR) and/or the Intersocietal Accreditation Commission (IAC):

• Freestanding imaging centers • Independent diagnostic testing facilities • Nonphysician practitioners • Office-based imaging facilities • Physicians • Suppliers of advanced diagnostic imaging procedures

This accreditation requirement applies to the technical part of advanced diagnostic imaging procedures. For these purposes, advanced diagnostic imaging procedures exclude X-ray, ultrasound, fluoroscopy and mammography. Included are:

• Magnetic resonance imaging (MRI) • Magnetic resonance angiography (MRA) • Computed tomography (CT) • Echocardiograms • Nuclear medicine imaging, such as positron emission tomography (PET) • Single photon emission computed tomography (SPECT)

Note:

• Providers not accredited by the ACR or IAC by January 1, 2012, will not be eligible for payment for advanced diagnostic imaging services.

• This requirement will not apply to patients who are in the hospital or in hospital emergency departments. • This policy will not apply to hospitals, unless they own one of the above listed providers. • The accreditation process can take 9 to 12 months.*

*Note from IAC: The IAC accreditation review process generally takes approximately 8 to 12 weeks to complete and the decision returned to the facility. Review the IAC Policies & Procedures for complete details at www.intersocietal.org/iac/legal/policies.htm. Please note: The above requirements list only a portion of the full reimbursement directive as related to accreditation. For full requirements, please refer to the Mid-America Office Manual Supplement (Updated 1-2017)»

IAC Vascular Testing – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 3 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Anthem BCBS (Virginia) REFERENCED FROM ANTHEM PROVIDER MANUAL Diagnostic Imaging Accreditation: Within 30 days of receipt of a written request, participating provider shall provide to Anthem such information as may be requested concerning diagnostic imaging services, equipment, licensure and/or accreditation. Participating providers shall provide such information in the manner and format reasonably required by Anthem (including, without limitation, using a web-based tool). Additionally, after making its original submission of this information to Anthem, whenever any material change occurs with respect to Provider’s diagnostic imaging services, equipment, licensure and/or accreditation, Provider shall update Anthem on such change within 30 days of the change (unless a shorter timeframe is required elsewhere in this Agreement). Providers that perform or conduct any Ultrasound, CT, CTA, MRI, MRA, MRS, PET, Cardiac Echocardiography and/or Nuclear/Nuclear Cardiology studies shall be accredited by the American College of Radiology (ACR), Intersocietal Accreditation Commission (IAC), American Institute of Ultrasound in Medicine (AIUM) or the American Society of Breast Surgeons (ASBS) for each piece of equipment utilized in such studies. Provider has one year from the acquisition of the modality to obtain accreditation. Provider will make no charge or render no bill to any Plan, the Covered Individual, or the Covered Individual’s guarantor for any of the studies listed above, and they shall have no obligation to make any payment to anyone, including Provider, for such studies, unless the studies are performed on accredited equipment as specified above. Please note: The above requirements list only a portion of the full reimbursement directive as related to accreditation. For full requirements, please refer to the Anthem Provider Manual»

Network Update Regarding OptiNet: Complete your Medicare Advantage AIM OptiNet® registration for X-ray, ultrasound or high-tech imaging services by Jan. 1, 2017 All participating Medicare Advantage providers who provide imaging services must complete registration for AIM’s online registration tool, OptiNet. OptiNet will collect modality-specific data from providers who render X-ray, ultrasound (abdominal/retroperitoneum, gynecological and obstetrical services only at this time), Magnetic Resonance (MR), Computed Tomography (CT), nuclear medicine (NUC), positron emission tomography (PET) and echocardiograph imaging services. Areas of assessment include facility qualifications, technician and physician qualifications, accreditation, equipment and technical registration. These data will be used to calculate site scores for providers who render imaging services for our individual Medicare Advantage members. All participating providers who provide imaging services, including x-rays and ultrasounds as noted above, must complete the registration. Providers who do not register, who score less than 76 or who do not complete the survey by Jan. 1, 2017 will receive a line-item denial for the technical component of the outpatient diagnostic imaging service only. This includes providers who have delegated risk arrangements and who may see Anthem members outside of those risk arrangements. Please note: This health plan requires OptiNet participation. Accreditation is one of the four primary factors in the OptiNet scoring formula.

Read the complete announcement on the Anthem BCBS website»

IAC Vascular Testing – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 4 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Anthem Blue Cross Medicare Advantage (CA, CT, IN, KY, ME, MO, OH, WI) On November 1, 2015, Anthem Blue Cross Medicare Advantage plans began collecting information about the imaging capabilities of all Anthem Blue Cross Medicare Advantage contracted providers who provide the technical component of a number of outpatient diagnostic imaging services for our individual Medicare Advantage members.

• Computed Tomography (CT) • Magnetic Resonance (MR) • Positron Emission Tomography (PET) • Nuclear Medicine (NUC) • Ultrasound • X-Ray • Echocardiograph

AIM’s online registration tool, OptiNet®, will continue to collect modality-specific data from providers who render imaging services in areas such as: facility qualifications, technician and physician qualifications, accreditation, equipment, and technical registration. This information is used to determine conformance to industry-recognized standards, including those established by the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC). Network Update Regarding OptiNet: Complete your Medicare Advantage AIM OptiNet® registration for X-ray, ultrasound or high-tech imaging services by Jan. 1, 2017 All participating Medicare Advantage providers who provide imaging services must complete registration for AIM’s online registration tool, OptiNet. OptiNet will collect modality-specific data from providers who render X-ray, ultrasound (abdominal/retroperitoneum, gynecological and obstetrical services only at this time), Magnetic Resonance (MR), Computed Tomography (CT), nuclear medicine (NUC), positron emission tomography (PET) and echocardiograph imaging services. Areas of assessment include facility qualifications, technician and physician qualifications, accreditation, equipment and technical registration. These data will be used to calculate site scores for providers who render imaging services for our individual Medicare Advantage members. All participating providers who provide imaging services, including x-rays and ultrasounds as noted above, must complete the registration. Providers who do not register, who score less than 76 or who do not complete the survey by Jan. 1, 2017 will receive a line-item denial for the technical component of the outpatient diagnostic imaging service only. This includes providers who have delegated risk arrangements and who may see Anthem members outside of those risk arrangements. Please note: This health plan requires OptiNet participation. Accreditation is one of the four primary factors in the OptiNet scoring formula.

Read the complete announcement on the Anthem BCBS website»

IAC Vascular Testing – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 5 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Arkansas BlueCross BlueShield REFERENCED FROM ABCBS PROVIDER MANUAL (JANUARY 2017) High tech imaging center participation standards The following participation standards will become effective January 1, 2015, for all imaging centers participating in the Preferred Payment Plan, Medi-Pak® Advantage PFFS, Medi-Pak® Advantage LPPO, Medi-Pak® Advantage HMO, Arkansas’ FirstSource® PPO, True Blue PPO and Health Advantage HMO (the foregoing referred to collectively hereinafter as the “networks”). These standards and requirements are intended to promote reasonable and consistent quality and safety standards for the provision of imaging services. These standards apply to all non-hospital based imaging centers (ICs), including ICs and in-office ICs performing high-tech imaging procedures which include computed tomography (CT), magnetic resonance (MR), positron emission tomography (PET), nuclear medicine and nuclear cardiology services. ICs must maintain ongoing compliance with these standards as a condition of participation in the networks. II. Modality Specific Guidelines

A. Computed Tomography (CT), Magnetic Resonance (MR) and/or Positron Emission Tomography (PET) Services

6. Accreditation: All ICs who perform CT, MRI, breast MRI, nuclear medicine imaging, nuclear cardiology and PET must have

acceptable accreditation for each modality as follows:

a. CT: American College of Radiology (ACR); or Intersocietal Accreditation Commission (IAC) CT; b. MRI and Breast MRI: ACR or IAC MRI; and c. PET, Nuclear Medicine and Nuclear Cardiology: ACR or IAC Nuclear/PET

Imaging Centers Purchased by Hospitals Per the terms of participation for the Arkansas Blue Cross and Blue Shield Preferred Payment Plan, Health Advantage HMO network, and USAble Corporation’s Arkansas’ FirstSource® and True Blue PPO networks, advanced imaging centers must be accredited by one of the agencies that meets approval per these networks’ required accreditation program. This includes advanced imaging centers purchased by another organization, including hospitals. In most situations, a currently accredited imaging center can simply notify the accrediting agency (e.g. American College of Radiology or Intersocietal Accreditation Commission) and ask for a certificate with the new organization’s name applied to it. Arkansas Blue Cross, Health Advantage, and USAble Corporation will need a copy of the new certificate. Please understand that if the imaging center’s new owner is a hospital, the hospital’s Joint Commission accreditation does not automatically apply. In order for this to apply, the hospital must be performing both inpatient and outpatient imaging services and the imaging center must have been part of the on-site review performed by the Joint Commission when the accreditation was given. Please note: The above requirements list only a portion of the full reimbursement directive as related to accreditation. For more information on the ABCBS requirements, please review the ABCBS Provider Manual.

IAC Vascular Testing – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 6 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

BlueCross BlueShield of Alabama REFERENCED FROM BCBSAL WEBSITE (Note from IAC: The information about our programs listed below from the BCBCAL website was updated for this document to reflect the current program names [i.e., ICANL is now IAC Nuclear/PET, etc.]). Radiology Facility and Technology Assessment Program All Blue Cross and Blue Shield of Alabama Preferred Radiology (PRP) Providers must have current accreditation through American College of Radiology (ACR) and or Intersocietal Accreditation Commission (IAC). Read more on the BCBSAL website» Exhibit B: Credentialing Criteria (reference) At least one of the following accreditation standards must be met by Provider and Provider’s practice site at all times: Current American College of Radiology (ACR), IAC Nuclear/PET (formerly ICANL), IAC MRI (formerly ICAMRL), IAC CT (formerly ICACTL), or other national accreditation agencies or standards as determined by Corporation, as applicable. Accreditation must be maintained for every example of the following devices at each practice site: magnetic resonance imaging (MRI), computed tomography (CT) and PET. Please note: The above requirements list only a portion of the full reimbursement directive as related to accreditation. For complete requirements, review the Highmark Provider Equipment Standards for Continued Participation on the BCBSAL website (https://providers.bcbsal.org).

IAC Vascular Testing – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 7 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

BlueCross BlueShield of Georgia On Nov. 1, 2015, BCBSGa Medicare Advantage plans began collecting information about the imaging capabilities of all BCBSGa Medicare Advantage contracted providers who provide the technical component of a number of outpatient diagnostic imaging services for our individual Medicare Advantage members.

AIM’s online registration tool, OptiNet®, will continue to collect modality-specific data from providers who render imaging services in areas such as: facility qualifications, technician and physician qualifications, accreditation, equipment, and technical registration. This information is used to determine conformance to industry-recognized standards, including those established by the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC).

Please note: This health plan requires OptiNet participation. Accreditation is one of the four primary factors in the OptiNet scoring formula.

The provider registration is available online at www.aimspecialtyhealth.com/goweb. Simply select Anthem MA from the drop down menu. If you have questions or need help completing the registration, please call AIM Customer Service at 800-252-2021.

Please note that the line-item denial for a site score below 76 for the applicable modality applies only to individual Medicare Advantage claims at this time. Check Important Medicare Advantage Updates at www.bcbsga.com/medicareprovider.

Update – February 2017

Medicare Advantage AIM OptiNet Imaging Services Initiative Postponed

Recent issues of Network Update and previous Important Medicare Advantage Updates portal postings have included information about an initiative administered by AIM Specialty Health® to collect information about imaging capabilities of our individual Medicare Advantage providers. This initiative has been postponed from Jan. 1, 2017 to April 1, 2017. Medicare Advantage providers will not be subject to the requirement to have a specific OptiNet score to be reimbursed for outpatient diagnostic imaging services at this time. Although there is no reimbursement impact at this time, Blue Cross and Blue Shield of Georgia (BCBSGA) continues to encourage network providers to submit imaging services data for the AIM Specialty Health initiative. The provider registration is available online at www.aimspecialtyhealth.com/goweb.

All participating Medicare Advantage providers who provide imaging services must complete registration for AIM’s online registration tool, OptiNet. OptiNet will collect modality-specific data from providers who render X-ray, ultrasound (abdominal/retroperitoneum, gynecological and obstetrical services only at this time), Magnetic Resonance (MR), Computed Tomography (CT), nuclear medicine (NUC), positron emission tomography (PET) and echocardiograph imaging services. Areas of assessment include facility qualifications, technician and physician qualifications, accreditation, equipment and technical registration.

These data will be used to calculate site scores for providers who render imaging services for our individual Medicare Advantage members. Read the complete announcement on the BCBSGA website.

IAC Vascular Testing – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 8 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

BlueCross BlueShield of Louisiana REFERENCED FROM BCBSLA WEBSITE *Effective 1/1/2010, BCBSLA requires all free-standing diagnostic radiology facilities to be accredited for all modalities they perform services for by either ACR or IAC. Read more about the credentialing criteria specific to diagnostic radiology facilities at www.bcbsla.com/Providers/Credentialing/Pages/13_871.aspx. OptiNet AIM Specialty Health SM (AIM)* is gathering information about the capabilities of all Blue Cross and HMO Louisiana, Inc., contracted providers who provide the technical component of the following diagnostic imaging services:

• Computed Tomography (CT/CTA) • Echocardiography • Magnetic Resonance Imaging (MRI/MRA) • Mammography • Nuclear Cardiology • Positron Emission Tomography (PET) • Ultrasound • X-Ray

Using AIM's online assessment tool, OptiNet, we gather information about our providers' training and capability related to technical imaging services, imaging equipment, capacity and access. The tool will also gather information about providers' compliance with industry standards, such as those established by The Joint Commission (formerly JCAHO), the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC). Providers may access the OptiNet assessment through our iLinkBLUEProvider Suite. OptiNet allows providers to start, stop and save the assessment as necessary. All network providers who provide imaging services are required to complete the assessment through OptiNet®. This includes hospitals, freestanding diagnostic centers and physician clinics. The information gathered will be used to rate our providers and make determinations on an acceptable score for our future transparency programs and/or future network programs. Key Points (full PDF): While the OptiNet assessment collects a wide range of data, there are a few key factors that drive the overall modality scores. In order for a site to receive a score of an A or a B, the following key factors need to be in place: Please note: This health plan requires OptiNet participation. Accreditation is one of the four primary factors in the OptiNet scoring formula.

• Physician staffing: (25% of weighted modality score) There should be at least one Board-certified radiologist on-site at the facility. In addition to radiologists, other specialties are also recognized for specific modalities. In addition to board-certified specialties, certain modalities will also recognize interpretation volume, CME and training levels.

• Technologist staffing: (25% of weighted modality score) There should be at least one technologist with modality-specific certification. Technologists with basic radiology certification (ARRT(R) certification) earn zero points with the exception of the x-ray modality.

• Machine accreditation: (10% of weighted modality score) Machines should be certified by ACR, IAC or one of the other recognized accrediting bodies.

• Machine quality: (15% of weighted modality score) Machine quality does contribute to the overall score. For more about the OptiNet program, visit www.bcbsla.com/Providers/Credentialing/Pages/OptiNet.aspx.

IAC Vascular Testing – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 9 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

BlueCross Blue Shield of Massachusetts To receive reimbursement, all professional providers, technical providers, and non-hospital-based free-standing facilities must have privileges for the following diagnostic imaging services:

• Angiography, including cardiac catheterization • Bone densitometry • CT Scan • Endovenous laser treatment • Fluoroscopy • Mammography X-ray

• MRI, including magnetic resonance angiography • Nuclear cardiology • Nuclear medicine, including PET scan • Ultrasound including all vascular ultrasound and

echocardiography • X-ray

BCBS of Massachusetts applies distinct reimbursement criteria to technical providers — who perform imaging services — and professional providers — who read and interpret the images. Apply to provide technical services:

• You can apply to be reimbursed for costs for owning, leasing, or use of diagnostic imaging for the services listed below. • Complete a separate application for each location where you own, lease, or otherwise incur the full usage cost of diagnostic

imaging equipment for any of the modalities listed below. • If there are changes to the diagnostic imaging equipment or service site information, submit a new copy of the application with

an explanation attached.

For the following modalities, use the TDI Privileging Application: Note from IAC: Only the modalities that require IAC accreditation are listed below, for full listing of requirements by modality, please visit the BCBSMA website.

Modality Technical requirements

Cardiac CT Scan Accreditation from IAC CT or ACR

Endovenous Laser Treatment Free-standing facility and hospitals Accreditation from IAC Vein Center

Magnetic Resonance Imaging (MRI) Accreditation from IAC MRI or ACR

Ultrasound, Vascular Accreditation from IAC Vascular Testing or ACR

For complete requirements, visit https://provider.bluecrossma.com click on Office Resources>> Enrollment>> Privileging.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 10 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

BlueCross BlueShield of Mississippi REFERENCED FROM THE BCBSMS WEBSITE BCBS of Mississippi requires all network providers billing the technical component of the CT to be accredited in CT by the IAC or ACR in the following areas: Cardiac Computed Tomographic Angiography (CCTA) Provider Accreditation for CCTA – Network Providers: Effective 01/01/2013, all Network Providers billing the technical component of the CT must be accredited in Coronary CTA by the Intersocietal Accreditation Commission (IAC) or a Cardiac CT module by the American College of Radiology (ACR). The professional component of the CT will be reimbursed based upon the accreditation of the facility as the ACR and the IAC facility accreditations require that interpreting professional physicians also be accredited by the ACR or Society of Cardiovascular Computed Tomography, respectively. Computed Tomography (CAT Scan) and Computed Tomographic Angiography (CTA) of the Chest and Thorax Provider Accreditation for CT – Network Providers: All Network Providers billing the technical component of the CT must be accredited in CT by the Intersocietal Accreditation Commission (IAC) or a CT module by the American College of Radiology (ACR). The professional component of the CT will be reimbursed based upon the accreditation of the facility as the ACR and the IAC facility accreditations require that interpreting professional physicians also be accredited. Computed Tomography (CAT Scan) of the Cervical, Thoracic, and Lumbar Spine Provider Accreditation for CT – Network Providers: All Network Providers billing the technical component of the CT must be accredited in CT by the Intersocietal Accreditation Commission (IAC) or a CT module by the American College of Radiology (ACR). The professional component of the CT will be reimbursed based upon the accreditation of the facility as the ACR and the IAC facility accreditations require that interpreting professional physicians also be accredited. Computed Tomography (CAT Scan) and Computed Tomographic Angiography (CTA) of Extremity or Joint Provider Accreditation for CT – Network Providers: All Network Providers billing the technical component of the CT must be accredited in CT by the Intersocietal Accreditation Commission (IAC) or a CT module by the American College of Radiology (ACR). The professional component of the CT will be reimbursed based upon the accreditation of the facility as the ACR and the IAC facility accreditations require that interpreting professional physicians also be accredited. Computed Tomography (CAT Scan) and Computed Tomographic Angiography (CTA) of the Head and Neck Provider Accreditation for CT – Network Providers: All Network Providers billing the technical component of the CT must be accredited in CT by the Intersocietal Accreditation Commission (IAC) or a CT module by the American College of Radiology (ACR). The professional component of the CT will be reimbursed based upon the accreditation of the facility as the ACR and the IAC facility accreditations require that interpreting professional physicians also be accredited. Computed Tomography (CAT Scan) and Computed Tomographic Angiography (CTA) of the Abdomen and Pelvis Provider Accreditation for CT – Network Providers: All Network Providers billing the technical component of the CT must be accredited in CT by the Intersocietal Accreditation Commission (IAC) or a CT module by the American College of Radiology (ACR). The professional component of the CT will be reimbursed based upon the accreditation of the facility as the ACR and the IAC facility accreditations require that interpreting professional physicians also be accredited. Please note: The above requirements list only a portion of the full reimbursement directive as related to accreditation. To review the complete medical policies for CT, please visit www.bcbsms.com/index.php?q=member-medical-policy-search.html and use the search tool to locate any of the CT medical policies listed above.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 11 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

BlueCross BlueShield of North Carolina REFERENCED FROM BCBSNC WEBSITE Free Standing Radiology Facilities (Blue Medicare HMO and Blue Medicare PPO Networks Only) BlueCross and BlueShield of North Carolina partners with American Imaging Management (AIM) to implement the diagnostic imaging program for high-tech outpatient imaging services. BCBS of North Carolina implemented a credentialing and accreditation requirement as a condition for network participation for all freestanding diagnostic imaging providers and the equipment used to perform the following modalities: CT/CTA, MRI/MRA, PET, nuclear cardiology and echocardiography. The company requires that all freestanding diagnostic facilities be accredited by Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) or The Joint Commission (JCAHO) for any or all of the aforementioned modalities. For more information on the credentialing process as related to accreditation, please visit www.bcbsnc.com/content/providers/application/free-standing-radiology.htm.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 12 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

BlueCross BlueShield of South Carolina REFERENCED FROM BCBSSC WEBSITE Radiology Precertification Some groups require National Imaging Associates (NIA) to precertify certain advanced imaging services when performed and billed in an outpatient or office location. NIA is an independent company that handles precertification for certain imaging services on behalf of BlueCross. Review the Radiology Precertification information to learn more. National Imaging Associations, Inc. (NIA) will allow the ordering or delivering physician to get prior authorization for the services/procedures in the Radiology Program. We designed this guide to assist the delivering provider in getting prior authorization for NIA. On behalf of BlueCross BlueShield of South Carolina, NIA handles preauthorization for certain imaging services. NIA is an independent company. Services/Procedures Included in the Radiology Program*

• Computerized Axial Tomography (CAT) Scan • Positron Emission Tomography (PET) • Magnetic Resonance Imaging (MRI) • Magnetic Resonance Angiography (MRA)

*Non-emergency outpatient diagnostic imaging services performed in a freestanding imaging center, hospital outpatient setting or in-office via physician-owned high tech equipment preauthorization. For complete NIA requirements, download NIA’s Imaging Provider Handbook at www1.radmd.com/resources/imaging-provider-handbook.aspx.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 13 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

California Senate Bill 1237 (Medical Radiation Safety Act) Beginning July 1, 2013, facilities that furnish computed tomography (CT) services must be accredited by an organization that is approved by the Centers for Medicare and Medicaid Services (CMS), an accrediting agency approved by the Medical Board of California or the State Department of Public Health. This bill also requires the facility to report certain information to the department, the affected patient and the patient’s treating physician. The Intersocietal Accreditation Commission (IAC) has been designated as an approved accrediting organization. Here are the major points of the bill related to accreditation, CT facilities should be aware of: This bill would, commencing July 1, 2013, require facilities that furnish CT X-ray services to be accredited by an organization that is approved by the federal Centers for Medicare and Medicaid Services, an accrediting agency approved by the Medical Board of California, or the State Department of Public Health. The bill would also require the facility to report certain information to the department, the affected patient, and the patient's treating physician. SECTION 1: a) Commencing July 1, 2012, subject to subdivision (e), a person that uses a computed tomography (CT) X-ray system for human use

shall record the dose of radiation on every CT study produced during a CT examination. b) The facility conducting the study shall electronically send each CT study and protocol page that lists the technical factors and dose of

radiation to the electronic picture archiving and communications system. c) The displayed dose shall be verified annually by a medical physicist to ensure the displayed doses are within 20 percent of the true

measured dose measured in accordance with subdivision (f) unless the facility is accredited. d) Subject to subdivision (e), the radiology report of a CT study shall include the dose of radiation by either recording the dose within the

patient's radiology report or attaching the protocol page that includes the dose of radiation to the radiology report. e) The requirements of this section shall be limited to CT systems capable of calculating and displaying the dose. f) For the purposes of this section, dose of radiation shall be defined as one of the following:

• The computed tomography index volume (CTDI vol) and dose length product (DLP), as defined by the International Electrotechnical Commission (IEC) and recognized by the federal Food and Drug Administration (FDA).

• The dose unit as recommended by the American Association of Physicists in Medicine SEC. 2. Section 115112 is added to the Health and Safety Code, to read: 115112. Commencing July 1, 2013, facilities that furnish CT X-ray services shall be accredited by an organization that is approved by the federal Centers for Medicare and Medicaid Services, an accrediting agency approved by the Medical Board of California, or the State Department of Public Health. To review the entire chaptered version of the bill, click here. If your facility is not granted accreditation through one of the approved organizations by July 1, 2013, it will not receive reimbursement. Your facility must, at all times, maintain accreditation with an accrediting organization.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 14 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

eviCore Healthcare (National) Accreditations, Insurance, and Reporting Requirements:

1. Facilities seeking to furnish the technical component of advanced diagnostic imaging services in MR, MR Breast, CT, PET or NM, and Mammography under the eviCore program are required to be accredited in each module requested with one of the following: The American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), the American Society of Breast Surgeons (ASBS), Intersocietal Accreditation Commission (IAC) in MR, CT, NM/PET, and Echocardiography, The Joint Commission (TJC), or RadSite. The requirements of the accrediting organization must be met at all times to maintain reimbursement.

2. Facilities performing Cardiac procedures will be required to hold accreditation in that Cardiac module. See the Equipment Requirements for specifics.

3. New installations (brand new site, additional modality, replacement equipment) must have an application submitted to the ACR, IAC, TJC, RadSite, AIUM, and ASBS for accreditation within three (3) months of first clinical use.

Equipment Requirements (CT Standards):

• Current ACR, IAC, TJC, or RadSite accreditation for each CT on site.

• Current ACR, IAC, or TJC accreditation specifically recognizing Cardiac approval for each CT on site which is placed in the program. 1. RadSite CT accreditation doesn’t recognize sub modules, therefore will not be recognized for Cardiac approval.

• 4 slice per rotation (minimum).

• 16 slice per rotation (minimum) for Computed Tomographic Angiography (CTA) and Coronary Calcium scoring. 1. Those sites currently in the network will be allowed 24 months to comply with current requirements. 1st review at 12

months will include proof accreditation has been applied for. 2nd review at 24 months will include proof accreditation is held and confirmed via the accreditation board. If not accredited by the 24th month, termination will be recommended.

• 64 slice per rotation (minimum) for Cardiac Computed Tomography Angiography (CCTA). 1. Those sites currently in the network will be allowed 24 months to comply with current requirements. 1st review at 12

months will include proof accreditation has been applied for. 2nd review at 24 months will include proof accreditation is held and confirmed via the accreditation board. If not accredited by the 24th month, termination will be recommended.

• An eviCore credentialed physician must interpret all images. Quick Links:

• eviCore Healthcare Network Facility Standards • Accreditation Requirements Reviewed During Onsite Evaluation • Accreditation Modules

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 15 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Centers for Medicare and Medicaid Services (National) Accreditation of Advanced Diagnostic Imaging Suppliers

I. Background Section 135(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (P.L. 110-275) amended section 1834(e) of the Social Security Act (the Act). This amendment requires suppliers of the technical component of advanced diagnostic imaging (ADI) services to be accredited by a designated accrediting organization in order to receive Medicare reimbursement. This accreditation requirement for ADI suppliers was effective January 1, 2012. CMS has the statutory authority to designate accrediting organizations which accredit suppliers furnishing the technical component of ADI services. These requirements do not apply to hospitals or critical access hospitals. Under section 1861(d) of the Act, an ADI supplier is defined as a physician or other practitioner, or facility such as an Independent Diagnostic Testing Facility that furnishes the technical component of ADI services. “Technical component” is defined as all non-physician work performed by an ADI supplier, including administrative and non-physician personnel time and use of the ADI equipment and facility. Section 1834(e)(1)(B) of the Act defines “advanced diagnostic imaging” procedures as diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging procedures, such as positron emission tomography (PET). ADI procedures do not include x-ray, ultrasound, fluoroscopy procedures or diagnostic and screening mammography. Note: Diagnostic and screening mammography are subject to oversight by the U.S. Food and Drug Administration.

II. Information about the Advanced Diagnostic Imaging Accrediting Organizations • Application for CMS-designation as an ADI accrediting organization is a voluntary process. Application and re-application

procedures are set forth at 42 CFR 414.68(c). (A link to these regulations is available in the “Related Links” section below). • Each designated ADI accrediting organization may establish its own individual quality standards. At a minimum, these

standards must address, but are not limited to, the following areas: staff qualifications; equipment standards and safety; safety of patients, family and staff; medical records; and patient privacy.

• While the standards among the designated ADI accrediting organizations may vary, each accrediting organization must demonstrate that its accreditation program standards meet or exceed the standards established by statute and in the Medicare regulations.

• Designated ADI accrediting organizations are private entities which charge fees for their accreditation services. • Suppliers or other entities seeking additional information about CMS-designated ADI accrediting organizations and their

accreditation programs may contact the accrediting organizations listed below.

III. CMS-designated ADI Accrediting Organizations: • American College of Radiology (ACR) • Intersocietal Accreditation Commission (IAC) • RadSite • The Joint Commission (TJC)

For complete policy details, please visit the CMS website»

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 16 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Empire BlueCross BlueShield (New York) (REFERENCED FROM THE EMPIRE BLUE WEBSITE) Empire’s High-tech Radiology Imaging Services Program Beginning December 20, 2010, AIM will begin administering Empire’s high-tech radiology imaging services program for dates of service on or after January 1, 2011. Precertification will be required for the same high-tech radiology imaging services rendered to members whose benefits currently require precertification. Those services are as follows:

• Magnetic Resonance (MRI/MRA) • Positron Emission Tomography (PET) Scans • Computed Tomography (CT/CTA) • Nuclear Cardiology

Also, starting October 25, 2010, Empire began collecting information about the imaging capabilities of all contracted providers who provide the technical component of high-tech radiology imaging services in AIM's online assessment tool, OptiNet. OptiNet is an online imaging provider assessment tool that collects modality-specific data on advanced imaging providers in areas such as: facility qualifications, technician and physician qualifications, accreditation, and equipment. This information is used to determine conformance to industry-recognized standards, including those established by the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC). In addition to the transition, Empire will expand its diagnostic imaging management program on January 1, 2011, to include the following additional services:

• Stress Echocardiography (SE) • Resting Transthoracic Echocardiography (TTE) • Transesophageal Echocardiography (TEE)

AIM to provide voluntary pre-notification of echocardiography imaging services. For more information, please visit the Empire Blue website. Network Update Regarding OptiNet (September 2016): Please note: This health plan requires OptiNet participation. Accreditation is one of the four primary factors in the OptiNet scoring formula.

Empire BlueCross is dedicated to meeting the evolving needs of our members and ensuring that they receive the most appropriate care possible. We are pleased to introduce a new program for imaging services administered by AIM Specialty Health® (AIM).

EFFECTIVE November 1, 2015, Empire Medicare Advantage plans will begin collecting information about the imaging capabilities of all Empire Medicare Advantage contracted providers who provide the technical component of the following outpatient diagnostic imaging services for our individual Medicare Advantage members:

• Computed Tomography (CT) • Magnetic Resonance (MR) • Positron Emission Tomography (PET) • Nuclear Medicine (NUC) • Ultrasound • X-Ray • Echocardiograph

Emergency room outpatient diagnostic imaging services are excluded.

AIM’s online registration tool, OptiNet®, will continue to collect modality-specific data from providers who render imaging services in areas such as: facility qualifications, technician and physician qualifications, accreditation, equipment, and technical registration. This information is used to determine conformance to industry-recognized standards, including those established by the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC). Read the complete announcement on the Empire website»

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 17 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Florida Blue Advanced Imaging Service (AIS) Providers Quality Program AIS include such services as CT scans, MRIs, Nuclear Cardiology, and PET scans whereas contracted providers including physicians and Independent Diagnostic Testing Centers (IDTCs that render diagnostic imaging services to our members are required to participate in the Diagnostic Imaging Quality Program, which is a component of our Quality Improvement Program. We work collaboratively with National Imaging Associates (NIA), an independent vendor, to administer the Diagnostic Imaging Quality Program. A component of our Quality Programs, accreditation through either American College of Radiology (ACR) or Intersocietal Accreditation Commission (IAC) will be a requirement for obtaining a pre-authorization or Voluntary Predetermination for Select Services (Voluntary Predetermination for Select Services) from National Imaging Associates (NIA) for all lines of business. Payment for AIS will be conditional based upon having met our Quality Programs criteria. This requirement applies to those physicians and non-hospital facilities that perform outpatient imaging studies and bill on a CMS-1500 Health Insurance Claim Form or its electronic equivalent. This includes, but is not limited to, office-based physicians and IDTCs that provide and bill for the technical or global component of advanced imaging services. This requirement does not apply to a bill submitted solely for professional services related to advanced imaging. To learn about diagnostic imaging utilization management programs, refer to the NIA section. Accreditation can be obtained by contacting the ACR or IAC at the websites below.

• The American College of Radiology (ACR) • Intersocietal Accreditation Commission (IAC)

Physicians may continue to provide professional services to members and refer their patients needing AIS to an IDTC that has met the quality criteria. Notify your physician contract manager if you will no longer provide these services. Your Florida Blue participation status for professional services will not be affected. To learn about Diagnostic Imaging Quality Program, visit www.floridablue.com/providers/tools-resources/provider-manual and click on Physicians and Provider Manual (updated 1-2017).

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 18 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Highmark (DE, PA, WV) REFERENCED FROM HIGHMARK PROVIDER PRIVILEGING REQUIREMENTS (Effective September 2016) Since 2005, Highmark has maintained a Radiology Management Program to promote quality and patient safety of selected outpatient, non-emergency, advanced imaging services for its group customers and members. Highmark retains the services of NIA Magellan, a radiology benefits management firm, to support the program. Using Highmark medical policy and nationally accepted clinical criteria, Highmark and NIA Magellan work closely with imaging providers and ordering physicians to ensure that members receive the appropriate diagnostic imaging tests; avoid the inconvenience and expense of unnecessary and/or duplicative services; and reduce their exposure to unnecessary radiation. V. Requirements Specific to Each Modality – CT CT (At this time we do not privilege providers that utilize a cone-beam CT scanner.)

• CT must be performed at an imaging location that provides at least five of the following modalities: o Plain Films or DEXA (either or both count as one) o General or OB/GYN Ultrasound (either or both count as one) o Peripheral Vascular (PV) Ultrasound o Echocardiography/Stress o Echocardiography o Mammography o Computed Tomography/Computed Tomography Angiography/Cardiac Computed Tomography Angiography (CT/CTA/CCTA)

(individually or any combination count as one) o Magnetic Resonance Imaging/Magnetic Resonance Angiography (MRI/MRA) o Fluoroscopy o Nuclear Medicine/Nuclear Cardiology

• Hours of operation requirement – Must offer diagnostic imaging services for a minimum of 40 hours per week • Must be performed by an appropriately licensed or certified technologist (State certified, ARRT (CT) or ARRT (R) • Must have achieved accreditation by the American College of Radiology (ACR) or the Intersocietal Accreditation Commission

(IAC) CT upon submission of privileging application.

Please note: This is only a portion of the Highmark Provider Privileging Requirements as related to the requirements for accreditation. For complete requirements, please review the Highmark Provider Privileging Requirements on the Highmark website at www.highmark.com/health/pdfs/hm-repriv-requirements.pdf.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 19 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Horizon Blue Cross Blue Shield of New Jersey REFERENCED FROM HBCBSNJ MEDICAL POLICY MANUAL (3/11/2014) (Note from IAC: The information about our programs listed below from the HBCBSNJ Medical Policy Manual was updated for this document to reflect the current program names [i.e., ICAEL is now IAC Echocardiography, etc.]). Standards for Diagnostic Radiology/Imaging Facilities/Freestanding-Office including Surgi-Centers and Diagnostic Dental - Radiographic Imaging Horizon BCBSNJ has adopted the standards set forth in this policy to evaluate outpatient diagnostic/therapeutic radiology/ imaging services. The standards focus on the new digital radiography systems, fluoroscopy (including c-arm), interventional radiology, CT, MRI, ultrasound, echocardiography, mammography, nuclear medicine, nuclear cardiology, PET, PET/CT, Cardiac PET and Nuclear/PET in Diagnostic Radiology/Imaging Facilities/Freestanding-Physician Offices, Hospitals including Surgi-Centers and Diagnostic Dental Offices. Accreditation/Certification Requirements (note Modality Specific Modules are required for the below services): Modality: ACR IAC AIUM AACE ASBS

CT Head/Neck Neurological

Sinus/Temporal bone

Chest Body

Abdomen

Cardiac

Adult/Pediatric Coronary CTA

Calcium Scoring

Vascular/other

POLICY Facilities, free standing radiology/diagnostic imaging centers physician offices and radiation therapy providers performing radiology/imaging services or radiation therapy/oncology must comply with the quality standards set forth in the table below. New or newly installed used equipment wherein accreditation is required, must have an application submitted to the accrediting organization within three (3) months of first clinical use and accreditation must be obtained within six (6) months of first clinical use. All other equipment that is not subject to accreditation must comply with standards as set forth below without exception or modality privileges will be deactivated. In addition, all radiology/imaging centers must have undergone a site visit by Horizon BCBSNJ or designated representative prior to approval of participation for the contracted radiology/imaging center. Ambulatory Surgi Centers providing any imaging may be subject to a site visit and must comply with Horizon BCBSNJ’s quality standards as set forth in this document. Cardiologist or providers performing nuclear stress test and approved mobile providers may be subject to a site visit as needed and must adhere to the quality standards set forth. PRACTICE/SITE/TECHNOLOGISTS REQUIREMENTS A. Practice Requirements · All CT, MRI, Ultrasound, Nuclear Medicine and PET/CT scanners must be accredited for all applicable accreditation modules by either the American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), the Intersocietal Accreditation Commission (IAC) or the American Society of Breast Surgeons (ASBS). If a radiology site performs echocardiography, accreditation by IAC Echocardiography (formerly ICAEL) is required. Accreditation must include the appropriate modules for exams being performed. EQUIPMENT STANDARDS Equipment and accreditation standards must be met at all times. All MRI, CT, PET/CT, nuclear medicine, ultrasound and x-ray devices must be DICOM compatible. These standards are subject to regular and/or as needed review and will change as hardware and software technology evolves, and quality standards from appropriate accrediting organizations, such as the ACR, IAC, AIUM and/or ASBS. Please note: The above requirements list only a portion of the complete Horizon BCBSNJ policy for Diagnostic Radiology to show the portions related to accreditation only. To review the complete policy for Horizon BCBSNJ, please visit https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf and click on the Search Tab and enter Standards for Diagnostic Radiology/Imaging Facilities/Freestanding-Office including Surgi-Centers and Diagnostic Dental - Radiographic Imaging.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 20 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Independence Blue Cross Group (Philadelphia and Southeastern PA) Network Participation and Credentialing Independence requires that all providers be Medicare-certified; in addition, ancillary providers must be accredited by a third-party organization recognized by Independence:

Provider Type Accrediting or Certifying Organizations* Accreditation Required

Portable/Mobile X-Ray ACR, Joint Commission, IAC YES

Radiology – Advanced Diagnostic Imaging ACR, IAC, Joint Commission YES

*At the Plan’s discretion, the Plan may recognize any approved accrediting organization deemed acceptable by CMS. For complete details about Independence Network Participation and Credentialing Program, please visit www.ibx.com/providers/interactive_tools/credentialing/index.html.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 21 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Minnesota House Bill 2276 Effective August 1, 2013, Minnesota facilities and hospitals that furnish advanced diagnostic imaging (ADI) services (inclusive of Nuclear/PET, MRI and CT) must be accredited by an organization approved by the United States Department of Health and Human Services in order to receive reimbursement. The Intersocietal Accreditation Commission (IAC) has been designated as an approved accrediting organization. Here are the major points of the bill related to accreditation, facilities should be aware of: SECTION 1 (SUBDIVISION 2) Accreditation required. (a)(1) Except as otherwise provided in paragraph (b), advanced diagnostic imaging services eligible for reimbursement from any source, including, but not limited to, the individual receiving such services and any individual or group insurance contract, plan, or policy delivered in this state, including, but not limited to, private health insurance plans, workers' compensation insurance, motor vehicle insurance, the State Employee Group Insurance Program (SEGIP), and other state health care programs, shall be reimbursed only if the facility at which the service has been conducted and processed is accredited by one of the following entities: (i) American College of Radiology (ACR); (ii) Intersocietal Accreditation Commission (IAC); (iii) the Joint Commission; or (iv) other relevant accreditation organization designated by the secretary of the United States Department of Health and Human Services pursuant to United States Code, title 42, section 1395M. (2) All accreditation standards recognized under this section must include, but are not limited to: (i) provisions establishing qualifications of the physician; (ii) standards for quality control and routine performance monitoring by a medical physicist; (iii) qualifications of the technologist, including minimum standards of supervised clinical experience; (iv) guidelines for personnel and patient safety; and (v) standards for initial and ongoing quality control using clinical image review and quantitative testing. (b) Any facility that performs advanced diagnostic imaging services and is eligible to receive reimbursement for such services from any source in paragraph (a)(1) must obtain accreditation by August 1, 2013. Thereafter, all facilities that provide advanced diagnostic imaging services in the state must obtain accreditation prior to commencing operations and must, at all times, maintain accreditation with an accrediting organization as provided in paragraph (a). Subd. 3. Reporting. (a) Advanced diagnostic imaging facilities and providers of advanced diagnostic imaging services must annually report to the commissioner demonstration of accreditation as required under this section. (b) The commissioner may promulgate any rules necessary to administer the reporting required under paragraph (a). View the full requirements for bill» If your facility is not granted accreditation through one of the approved organizations by August 1, 2013, it will not receive reimbursement. Your facility must, at all times, maintain accreditation with an accrediting organization. Read more on the Minnesota Department of Health website»

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 22 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

National Imaging Associates (NIA) (National) REFERENCED FROM NIA IMAGING PROVIDER HANDBOOK (REV 11/15) (Note from IAC: The information about our programs and websites listed below from the NIA Imaging Provider Handbook was updated for this document to reflect the current program names [i.e., ICACTL is now IAC CT, etc.]). Provider Assessment NIA Policy Provider assessment encompasses both credentialing and privileging. NIA employs credentialing criteria and decision-making processes in the review and selection of imaging providers for inclusion in our provider network. Our imaging facility credentialing criteria satisfy the requirements of applicable accreditation and regulatory bodies, in addition to those of our customers.

NIA’s privileging program policies establish reasonable and consistent standards for the performance of all diagnostic imaging services. The program establishes minimum participation guidelines that include facility accreditation, equipment capabilities, physician and technologist education, training and certification, documented procedures for handling patient emergencies, ACLS, ARLS or BLS certified physician supervision on-site during contrast and non-contrast enhanced procedures and physician on-site during normal business hours, and facility management components such as radiation safety guidelines (i.e. ALARA —As Low as Reasonably Achievable). These guidelines are established and refined with consideration of the American College of Radiology (ACR) and other accreditation bodies, diagnostic imaging common practice standards, updated literature reviews and new technology assessments. NIA provides ongoing monitoring of imaging practices and facilities. What NIA Will Do: Complete the online NIA Diagnostic Imaging Provider Assessment Application on RadMD.com. The online tool has intuitive user interface capability and is very easy to use. Submit all required documents, including documentation of current accreditation, licensure and/or certification and insurance. Incomplete applications will not be processed. The privileging portion requires that you:

• Comply with diagnostic imaging equipment standards (i.e. minimum MR Tesla strengths, CT slices, etc.). • Utilize appropriately certified technologists. • Maintain accreditation by the American College of Radiology (ACR) or Intersocietal Accreditation Commission (IAC) for all

modalities performed, as appropriate. • Maintain appropriate imaging policies and procedures (i.e. Radiation Safety, ALARA, etc.).

Quality Assessment Activities NIA Policy NIA conducts quality assessment activities with its network providers/facilities to:

• Support quality improvement initiatives. • Evaluate provider clinical practices against guidelines or standards. • Review potential quality of care concerns. • Assess non-accredited providers against NIA standards.*

NIA’s quality assessment includes activities such as image reviews, record reviews and on-site visits. *Acceptable recognized accreditation for providers includes: accreditation for MRI and CT by the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (formerly ICAMRL, ICACTL); accreditation for PET by the ACR or IAC Nuclear/PET (formerly ICANL); accreditation for Nuclear Cardiology by the ACR or IAC Nuclear/PET (formerly ICANL); accreditation for Peripheral Vascular Ultrasound by the ACR or IAC Vascular Testing (formerly ICAVL); accreditation for Echocardiography by IAC Echocardiography (formerly ICAEL); accreditation for Ob/Gyn Ultrasound by the ACR or AIUM; and accreditation for General Ultrasound by the ACR or AIUM. Please Note: The details above list only a small portion of NIA’s requirements as related to accreditation only. For complete NIA requirements, download NIA’s Imaging Provider Handbook at www1.radmd.com/resources/imaging-provider-handbook.aspx.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 23 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Regence BlueCross BlueShield (Utah, Oregon) & Blue Shield of Idaho (including select counties of Washington) REFERENCED FROM ORGANIZATIONAL PROVIDER CREDENTIALING CRITERIA FOR PARTICIPATION AND TERMINATION (10/2015) Organizational credentialing criteria for participation and termination To be eligible for participation, organizational providers must meet and maintain the following criteria adopted by the Company:

1) The organizational provider, where applicable by state requirements, must have a current, valid unrestricted permanent state license or certificate as an organizational provider recognized by the Company (see Section II).

2) The organizational provider must submit a complete, signed and dated application, and all required documentation. Recredentialing is conducted every three (3) years, at a minimum.

3) At the time of initial application, the organizational provider must not have any of the following sanctions imposed by Medicare, Medicaid, accrediting agencies or other state and federal agencies:

a. stop placement status; or b. denial of payment status; or c. temporary management status; or d. pending state charges, actions; or e. excluded or expelled status; or f. loss of accreditation, licensure or certification status.

4) The Company may review and consider the organizational provider’s history in making its decision relating to participation and continued participation on our networks, including, but not limited to, the following:

a. a suspended or revoked license, certification or registration; or b. actions taken by any state or governmental professional body; or c. sanctions of any nature taken against the organizational provider by any government program, including, but not

limited to, Medicare and Medicaid; or d. denial, limitation, suspension or termination of participation by any health care institution or plan; or e) loss of

accreditation; or e. prior history with the Company.

5) The organizational provider’s State license(s) and certification(s) must be currently free of any restrictions, limitations, conditions or sanctions (formal or informal).

6) Organizational providers must meet the following requirements: a. Ambulance: State license and Medicare certified b. Ambulatory Surgery Center: State license (if applicable), Medicare certified and Accreditation c. Durable Medical/Home Medical Equipment: Medicare enrolled and Accreditation d. Home Health Agency: State License and either Medicare certified or Accreditation with Medicare deemed status e. Home Infusion Therapy: State license (if applicable), Medicare certified and Accreditation f. Hospice: State license (if applicable) and either Medicare certified or Accreditation with Medicare deemed status g. Hospital: State License and either Medicare certified or Accreditation with Medicare deemed status h. Kidney Dialysis Center: State license (if applicable) and Medicare certified i. Clinical Laboratory: Medicare certified and Clinical Laboratory Improvement Amendments (CLIA) certified j. Mass Immunization Provider: Medicare enrolled k. Orthotics/Prosthetics: Medicare enrolled and Accreditation l. Radiology and Medical Imaging Center (Free Standing or Mobile): Medicare Certified and Accreditation m. Residential Treatment Facility: State license and/or Certification (if applicable) or Accreditation n. Skilled Nursing Facility: State license and either Medicare certified or Accreditation with Medicare deemed status

i. Facilities must have a CMS health inspection rating of at least 2 out of 5; and ii. If a facility has a CMS health inspection rating of 2, it must not have any “severe” health deficiencies as

defined by CMS. o. Sleep Disorder Center: Medicare Certified and Accreditation p. Substance Abuse, Alcohol and Drug Treatment Facility: State license and/or Certification (if applicable) or

Accreditation. 7) The organizational provider’s accreditation must be from an accrediting organization that has Medicare deeming authority or

from an accrediting organization recognized by the Company. Please note: The details above list only a small portion of the complete Regence credentialing requirements as related to accreditation only. To review the complete policy, please visit the credential section of the Regence website at www.regence.com/web/regence_provider/credentialing and scroll down to Organizational Provider Credentialing Criteria for Participation and Termination.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 24 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

TriWest Healthcare Alliance (coverage map) Provider Credentialing Requirements The Department of Veterans Affairs (VA) may perform random onsite visits to provider locations through coordination with TriWest to inspect physical operations and/or review records of Veterans, speak with Veterans, review quality and completeness of accreditation, certification and credentialing, privileging and licensing documentation.

Additional Credentialing Requirements for Clinics/Facilities

Independent Physiological Lab (includes Cardiac Cath Lab and PET Center)

Positron Emission Tomography (PET) Centers shall be accredited by the American College of Radiology (ACR), the Intersocietal Accreditation Commission (IAC) or The Joint Commission (TJC) RadSite.

Facility of Magnetic Resonance Imaging (MRI), Freestanding

MRI and Breast MRI – Accredited by the American College of Radiology (ACR), the Intersocietal Accreditation Commission (IAC) or The Joint Commission (TJC) RadSite.

Facility of Portable XRay Accredited by the American College of Radiology (ACR) or the Intersocietal Accreditation Commission (IAC).

Outpatient Facility Providing Advanced Diagnostic Imaging

Accredited by American College of Radiology (ACR) or the Intersocietal Accreditation Commission (IAC), the Joint Commission or RadSite.

For complete details, please visit the TriWest Healthcare website»

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 25 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

UnitedHealthcare (National) REFERENCE: Physician, Health Care Professional, Facility and Ancillary Provider 2016 Administrative Guide Imaging accreditation (last reviewed by UnitedHealthcare January 2016) If you perform outpatient imaging studies and bill on a CMS -1500 or the electronic equivalent, you must obtain accreditation from one of the accrediting agencies listed below (Note from IAC: The information about our programs and websites listed below from the UnitedHealthcare Administrative Guide was updated for this document to reflect the current program names [i.e., ICAEL is now IAC Echocardiography] and websites).

• American College of Radiology (ACR) at acr.org • Intersocietal Accreditation Commission (IAC) at

intersocietal.org • IAC CT (formerly ICACTL) at intersocietal.org/ct • IAC MRI (formerly ICAMRL) at intersocietal.org/mri

• IAC Echocardiography (formerly ICAEL) at intersocietal.org/echo

• IAC Nuclear/PET (formerly ICANL) at intersocietal.org/nuclear

Accreditation is required for the following procedures: CT scan, MRI, Nuclear Medicine/Cardiology, PET scan and Echocardiography, in order to avoid the potential reimbursement reductions described below. This accreditation requirement applies to global and technical service claims. The accreditation process takes approximately 6 to 9 months to complete (Note from IAC: The IAC accreditation review process generally takes approximately 12 to 16 weeks to complete and the decision returned to the facility). This Imaging Accreditation Protocol promotes compliance with nationally recognized quality and safety standards. Upon notice from us, failure to obtain accreditation will affect your right to be reimbursed for procedures rendered using these modalities. As a result, an administrative claim reimbursement reduction for global and technical service claims, in part or in whole, will occur. Accreditation is obtained by submitting an application and fulfilling accreditation standards. Additional details regarding this accreditation requirement, including a list of the CPT codes for which accreditation is required, are available on UnitedHealthcareOnline.com → Clinician Resources → Radiology → Imaging Accreditation. For complete details, review the Physician, Health Care Professional, Facility and Ancillary Provider 2016 Administrative Guide. UPDATED - UNITEDHEALTHCARE STATEMENT REGARDING ACCREDITATION REQUIREMENTS UnitedHealthcare is committed to ensuring that all of our members have access to quality health care, including medical imaging services. We believe patients deserve assurance that equipment, technologists and physician practices are in compliance with professional society-developed performance standards for CT, MRI, PET, nuclear medicine/cardiology and echocardiography procedures (collectively referred to as "Advanced Imaging Studies"). Pursuant to UnitedHealthcare's Imaging Accreditation Program, we require accreditation for Advanced Imaging Studies. At this time, however, UnitedHealthcare will not require accreditation as a condition of eligibility for reimbursement, and therefore will not administratively deny claims for Advanced Imaging Studies based on lack of accreditation. When a decision is made to activate the claim denial component of the Imaging Accreditation Program, we will communicate the effective date to you. As a reminder, UnitedHealthcare recognizes the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC) standards and has enlisted their expertise in facilitating accreditation. Specific accreditation guidelines and standards are available on the ACR and IAC websites. Contact information for these organizations is listed below. UnitedHealthcare remains committed to advancing the quality and safety of imaging services through the Imaging Accreditation Program and will keep you apprised of any changes to our program. Accreditation Contact Information To confirm a providers accreditation status please refer to the American College of Radiology (ACR) or Intersocietal Accreditation Commission (IAC) website. UnitedHealthcare will recognize network providers who have achieved accreditation by these organizations. Intersocietal Accreditation Commission (IAC) intersocietal.org 800-838-2110

American College of Radiology (ACR) acr.org 800-770-0145

Stay up-to-date on any changes made to the accreditation requirements on the UnitedHealthCare website»

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 26 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

UnitedHealthCare - Oxford Health Plans (CT, NJ, NY) RADIOLOGY PROCEDURES REQUIRING PRECERTIFICATION FOR EVICORE HEALTHCARE ARRANGEMENT (full PDF) Accreditation requirements for participating providers: Note: Hospitals are currently excluded from the accreditation requirements listed below.

• All MRI, PET, and CT studies must be performed on an American College of Radiology ACR), Intersocietal Accreditation Commission (IAC), RadSite or The Joint Commission (TJC) accredited unit or at accredited facilities.

• Nuclear Medicine procedures noted with an * (in the pre-certification document) are only reimbursable to facilities with one of the following accreditations:

o American College of Radiology (ACR) o Intersocietal Accreditation Commission (IAC) Nuclear/PET (formerly ICANL)

ACCREDITATION REQUIREMENTS FOR RADIOLOGY SERVICES (full PDF)

In diagnostic imaging, accreditation programs have emerged as key initiatives to advance the quality and safety of imaging studies. It is important that Members receive services from facilities whose equipment, technologists, and physicians are in compliance with established accreditation performance standards.

All freestanding facilities and physician offices performing outpatient radiology imaging studies are required to obtain and maintain accreditation as a condition for reimbursement for the below services.

Note: *Nuclear Medicine procedures noted with an (*) are only reimbursable to radiologists when they have the appropriate certification.

Please see Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement for applicable CPT codes. Oxford has engaged eviCore healthcare to manage the accreditation process for our provider network. Accreditations should be faxed to eviCore healthcare at 866-699-8160 with the Accreditation Fax Cover sheet that can be found on the eviCore healthcare website at www.evicore.com. To ensure prompt handling of the accreditation please ensure that all applicable facility and physician information is included. If you have specific questions about the application process for accreditation, contact the ACR or IAC on their websites or by phone. For questions about Oxford’s accreditation requirements, call 1-800-666-1353.

In addition to accreditation, all radiologists and radiology centers in New York (NY) and New Jersey (NJ), who are interested in participating in the Oxford network and/or radiologists and radiology centers that already participate in the Oxford network and want to add a modality to their practice must also be credentialed. Please refer to the policy titled Credentialing Guidelines: Participation in the eviCore healthcare Network for additional information.

Exception:

• Radiologists and radiology centers performing outpatient radiology imaging studies in Connecticut (CT) are excluded from credentialing requirements (accreditation requirements are applicable).

• Hospitals performing outpatient radiology imaging studies are excluded from the accreditation requirements. All radiologists, radiology centers, and cardiologists in NY, NJ and CT who are currently participating in the Oxford network or wish to participate in the Oxford network and perform Coronary CT Angiography (CCTA) must also be credentialed. Refer to the policy titled Credentialing Guidelines: Participation in the eviCore healthcare Network for additional information.

IAC CT (formerly ICACTL) – Payment Policies (Last Reviewed by the IAC on 2/15/2017) 27 PLEASE NOTE: These policies are changed and updated regularly by the insurance carriers and list requirements as related to IAC accreditation only. Therefore, the IAC recommends that applicant facilities contact the insurance carriers in their area for the most accurate and current information to ensure compliance with reimbursement requirements at all times. Further questions about IAC accreditation as related to reimbursement should be e-mailed to reimbursement@intersocietal.org.

Wellmark BCBS (Iowa, South Dakota) REFERENCED FROM WELLMARK PROVIDER GUIDE

Facility/Entity Accreditation/CMS Requirements All facilities/entities must have at least one of the following licenses/certifications/accreditations to meet credentialing requirements: Radiology/Imaging Center (including, but not limited to, the following types of centers):

• General Radiology • CT, CTA • Echocardiography • Mammography • MRI, MRA

• Nuclear Cardiology • PET Scan • Radiation Oncology • Ultrasound • Portable X-Ray

Centers offering any of the services listed immediately below must be accredited by ACR or one of the accrediting agencies of the Intersocietal Accreditation Commission (IAC Vascular Testing, IAC Echocardiography, IAC Nuclear/PET, IAC MRI or IAC CT):

• CT • CTA • Nuclear Cardiology • Echocardiography

• PET • PET/CT • MRI • MRA

If the center does not offer any of the services above, it must be accredited by AAAHC, The Joint Commission, ACR, or one of the accreditation agencies of the Intersocietal Accreditation Commission (IAC Vascular Testing, IAC Echocardiography, IAC Nuclear/PET, IAC MRI or IAC CT). Please note: The above requirements list only a portion of the full reimbursement directive. Please refer to the Wellmark Provider Guide (updated January 2017) for additional information on the complete requirements and for specific requirements for other modalities.