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Medicaid Management Information Systems Maine Integrated Health Management Solution


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10.1View Attachments


If a user needs to review any attachments associated with an authorization request, follow the steps below:

  1. Select the View Attachments button from the Authorization Detail screen as shown in Figure 10-5: View Attachment Button.

Figure 10 23: View Attachment Button



  1. The View Attachment window will open with an Attachments drop-down menu, as shown in Figure 10-6: View Attachment.

Figure 10 24: View Attachment



  1. Select the drop-down menu to view all attachments and click on the name of the attachment you would like to view, as shown in Figure 10-6: View Attachment.

11.Print Detail


Providers rendering services on a PA may want to print a copy of the authorization for their medical records.

To print the authorization details, follow the steps in Section 10: View Authorization Status to navigate to the Authorization Details page, then:



  1. Select the Print Detail button from the Authorization Detail screen as shown in Figure 11-1: Print Detail.

Figure 11 25: Print Detail

2. The Authorization Detail screen will populate, as depicted in Figure 11-2: Authorization Detail.


  1. Select the Print button at the bottom of the Authorization Detail screen to print.

Figure 11 26: Authorization Detail


  1. CT and PET CPT Procedure Codes


Table 6 contains a list of CT and PET codes that require a PA for dates of service rendered March 1st, 2014 and after, with the following exceptions:

  • MaineCare members under age 21

  • MaineCare members over age 65

  • Services rendered in an emergency room setting

  • Services rendered during an inpatient stay

In some cases, other exemptions or rules may apply. For specific information, please reference the appropriate section of Maine Medicaid Policy at the link provided:

http://www.maine.gov/sos/cec/rules/10/ch101.htm

NOTE: Submission instructions for these CT and PET (radiology) codes are available in the Pathways Radiology Prior Authorization Request Guide at the link provided below:

https://mainecare.maine.gov/Provider%20Forms/Forms/Publication.aspx?RootFolder=%2fProvider%20Forms%2fAuthorizations%20Pathways&FolderCTID=&View=%7b550DD634%2d668F%2d47E9%2dB0DD%2d93CDCC1CD721%7d

Table 6: CT and PET Codes



Service Class

CPT Proc Code

Description

Prior Authorization Required?

Computerized Tomographys (CT)

70450

Brain /Head wo contrast

Y

Computerized Tomographys (CT)

70460

Brain/Head w/contrast

Y

Computerized Tomographys (CT)

70470

Brain/Head w/wo contrast

Y

Computerized Tomographys (CT)

70480

Orbits wo contrast

Y

Computerized Tomographys (CT)

70481

Orbits w/contrast

Y

Computerized Tomographys (CT)

70482

Orbits w/wo contrast

Y

Computerized Tomographys (CT)

70486

Sinus wo contrast

Y

Computerized Tomographys (CT)

70487

Sinus w/ contrast

Y

Computerized Tomographys (CT)

70488

Sinus w/wo contrast

Y

Computerized Tomographys (CT)

70490

Neck, Soft Tissue w/wo contrast

Y

Computerized Tomographys (CT)

70491

Neck, Soft Tissue w/contrast

Y

Computerized Tomographys (CT)

70492

Neck, Soft Tissue w/wo contrast

Y

Computerized Tomographys (CT)

70496

Angiogram Head

Y

Computerized Tomographys (CT)

70498

Angiogram Neck

Y

Computerized Tomographys (CT)

71250

Chest wo contrast

Y

Computerized Tomographys (CT)

71260

Chest w/contrast

Y

Computerized Tomographys (CT)

71270

Chest w/wo contrast

Y

Computerized Tomographys (CT)

71275

Angiogram, Chest w/contrast

Y

Computerized Tomographys (CT)

72125

Spine Cervical wo contrast

Y

Computerized Tomographys (CT)

72126

Spine Cervical w/contrast

Y

Computerized Tomographys (CT)

72127

Spine Cervical w/wo contrast

Y

Computerized Tomographys (CT)

72128

Spine, Thoracic wo contrast

Y

Computerized Tomographys (CT)

72129

Spine, Thoracic w/contrast

Y

Computerized Tomographys (CT)

72130

Spine, Thoracic w/wo contrast

Y

Computerized Tomographys (CT)

72131

Spine, Lumbar wo contrast

Y

Computerized Tomographys (CT)

72132

Spine, Lumbar w/contrast

Y

Computerized Tomographys (CT)

72133

Spine, Lumbar w/wo contrast

Y

Computerized Tomographys (CT)

72191

Pelvis Angiogram w/contrast

Y

Computerized Tomographys (CT)

72192

Pelvis wo contrast

Y

Computerized Tomographys (CT)

72193

Pelvis w/contrast

Y

Computerized Tomographys (CT)

72194

Pelvis w/wo contrast

Y

Computerized Tomographys (CT)

72292

Sacroplasty

Y

Computerized Tomographys (CT)

73200

Upper Extremity wo contrast

Y

Computerized Tomographys (CT)

73201

Upper Extremity w/contrast

Y

Computerized Tomographys (CT)

73202

Upper Extremity w/wo contrast

Y

Computerized Tomographys (CT)

73206

Upper Extremity Angiogram w/contrast

Y

Computerized Tomographys (CT)

73700

Lower Extremity wo contrast

Y

Computerized Tomographys (CT)

73701

Lower Extremity w/contrast

Y

Computerized Tomographys (CT)

73702

Lower Extremity w/wo contrast

Y

Computerized Tomographys (CT)

73706

Lower Extremity Angiogram

Y

Computerized Tomographys (CT)

74150

Abdomen wo contrast

Y

Computerized Tomographys (CT)

74160

Abdomen w/contrast

Y

Computerized Tomographys (CT)

74170

Abdomen w/wo contrast

Y

Computerized Tomographys (CT)

74174

Abdomen & Pelvis, Angiogram w/wo contrast

Y

Computerized Tomographys (CT)

74175

Abdomen, Angiogram/AAA w/contrast

Y

Computerized Tomographys (CT)

74176

Abdomen & Pelvis, Renal Stone wo contrast

Y

Computerized Tomographys (CT)

74177

Abdomen & Pelvis, Enterography

Y

Computerized Tomographys (CT)

74178

Abdomen & Pelvis, Urogram w/wo contrast

Y

Computerized Tomographys (CT)

74261

Diagnostic Virtual Colonoscopy w/o contrast

Y

Computerized Tomographys (CT)

74262

Diagnostic Virtual Colonoscopy w/contrast

Y

Computerized Tomographys (CT)

74263

CT Colonoscopy is not reimbursable when used for screening

Y

Computerized Tomographys (CT)

75571

Heart, CACA wo contrast

Y

Computerized Tomographys (CT)

75572

Cardiac CT w/3d image

Y

Computerized Tomographys (CT)

75573

Cardiac CT w/3d image, congen

Y

Computerized Tomographys (CT)

75574

Cardiac CT angio heart, w/3d image

Y

Computerized Tomographys (CT)

75635

Abdomen, Angio Aorta Runoff w/contrast

Y

Computerized Tomographys (CT)

76380

CT limited/localized follow-up study

Y

Computerized Tomographys (CT)

77078

Bone Mineral Density Study one or more sites

Y

Computerized Tomographys (CT)

92025

Corneal Topography, unilateral or bilateral

Y

Positron Emission Tomography (PET)

78459

Myocardial Imaging, metabolic evaluation

Y

Positron Emission Tomography (PET)

78491

Myocardial imaging, positron emission tomography (PET), perfusion, single study at rest or stress

Y

Positron Emission Tomography (PET)

78492

Myocardial Imaging, perfusion, multiple studies at rest and/or stress

Y

Positron Emission Tomography (PET)

78608

Brain Imaging, metabolic evaluation

Y

Positron Emission Tomography (PET)

78609

Brain Imaging, perfusion

Y

Positron Emission Tomography (PET)

78811

Tumor imaging, positron emission tomography (PET); limited area (eg, chest, head/neck)

Y

Positron Emission Tomography (PET)

78812

Tumor imaging, positron emission tomography (PET); skull base to mid-thigh

Y

Positron Emission Tomography (PET)

78813

Tumor imaging, whole body

Y

Positron Emission Tomography (PET)

78814

Tumor imaging, w/CT, limited area (e.g., chest, head/neck)

Y

Positron Emission Tomography (PET)

78815

Tumor imaging, w/CT, skull base to mid-thigh

Y

Positron Emission Tomography (PET)

78816

Tumor imaging, w/CT, whole body

Y
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