MRI Left / Right, Bilat, w/o, w & w/o MRA · 501-686-2621 501-614-7509 Prior Authorization# NPI#...
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501-686-2621 501-614-7509 Prior Authorization# NPI# Insurance Rep Name/Phone Number MRI MRA Head w w/o Contrast MRV 70546 Neck w w/o Contrast 70549 Neck w/o Contrast 70547 Head w/o Contrast COW 70544 Abdomen w/o Contrast 74181 Abdomen w w/o Contrast 74183 Brain w/o Contrast 70551 Brain w w/o Contrast 70553 Orbits/IACS/Pituitary Bilat Breast MRI w w/o Contrast 77059 MRI Extremity Lower 73718 w/o Contrast - Left / Right Tib/Fib, Mid/Foreft, Femur, Foreft/Toes Extremity Upper Joint 73221 w/o Contrast - Left / Right Shoulder, Elbow, Wrist, Finger Soft Tissue Neck w/o Contrast 70540 Pelivs w/o Contrast 72195 Spine Cervical w/o Contrast 72141 Extremity Lower w w/o Contrast 73720 Tib/Fib, Mid/Foreft, Femur, Foreft/Toes Left / Right Extremity Lower Joint 73721 w/o Contrast - Left / Right Knee, Ankle, Mid/Hindfoot, Hip Extremity Upper w/o Contrast 73218 Scapula, Humerus, Forearm, Hand Left / Right Extremity Lower Joint 73723 w w/o Contrast - Left / Right Knee, Ankle, Mid/Hindfoot, Hip Extremity Upper w w/o Contrast 73220 Scapula, Humerus, Forearm, Hand Left / Right Extremity Upper Joint 73223 w w/o Contrast - Left / Right Shoulder, Elbow, Wrist, Finger Pelivs w w/o Contrast 72197 Soft Tissue, Neck w w/o Contrast 70543 Spine Cervical w w/o Contrast 72156 Spine Lumbar w/o Contrast 72148 Spine Lumbar w w/o Contrast 72158 Spine Thoracic w/o Contrast 72146 Spine Thoracic w w/o Contrast 72157 (*) Please bring medical ID card to appointment. (Please Print) Fax order to 501-614-7509 RAPA accepts most major insurance plans, including Blue Cross Blue Shield products, Aetna, Cigna, United Health Care and QualChoice QCA. Prior authorization is required by most commercial insurance companies. Please preauthorize before scheduling procedure. Pumps (Infusion, Insulin, Chemotherapy)* Aneurysm Clip or Surgery* Prosthetic Heart Valve* Middle Ear Prosthesis (Cochlear Implant)* Other: _____________________ Left / Right, Bilat, w/o, w & w/o 501-686-2621 MR/Arthrogram 73222 Shoulder OR Wrist OR Elbow Left / Right MR/Arthrogram 73722 Hip OR Knee - Left / Right Cell Phone Number CDSM HCPCS Code** AUC Modifier** **Required for Medicare Payment Only
Transcript of MRI Left / Right, Bilat, w/o, w & w/o MRA · 501-686-2621 501-614-7509 Prior Authorization# NPI#...
501-686-2621501-614-7509
Prior Authorization# NPI# Insurance Rep Name/Phone Number
MRI
MRAHead w w/o Contrast MRV 70546 Neck w w/o Contrast 70549Neck w/o Contrast 70547Head w/o Contrast COW 70544
Abdomen w/o Contrast 74181
Abdomen w w/o Contrast 74183
Brain w/o Contrast 70551
Brain w w/o Contrast 70553Orbits/IACS/Pituitary
Bilat Breast MRI w w/o Contrast 77059
MRI Extremity Lower 73718w/o Contrast - Left / RightTib/Fib, Mid/Foreft, Femur, Foreft/Toes
Extremity Upper Joint 73221w/o Contrast - Left / RightShoulder, Elbow, Wrist, Finger
Soft Tissue Neck w/o Contrast 70540
Pelivs w/o Contrast 72195
Spine Cervical w/o Contrast 72141Extremity Lower w w/o Contrast 73720Tib/Fib, Mid/Foreft, Femur, Foreft/ToesLeft / RightExtremity Lower Joint 73721w/o Contrast - Left / RightKnee, Ankle, Mid/Hindfoot, Hip
Extremity Upper w/o Contrast 73218Scapula, Humerus, Forearm, Hand Left / Right
Extremity Lower Joint 73723w w/o Contrast - Left / RightKnee, Ankle, Mid/Hindfoot, Hip
Extremity Upper w w/o Contrast 73220Scapula, Humerus, Forearm, Hand Left / Right
Extremity Upper Joint 73223w w/o Contrast - Left / RightShoulder, Elbow, Wrist, Finger
Pelivs w w/o Contrast 72197
Soft Tissue, Neck w w/o Contrast 70543
Spine Cervical w w/o Contrast 72156
Spine Lumbar w/o Contrast 72148
Spine Lumbar w w/o Contrast 72158
Spine Thoracic w/o Contrast 72146
Spine Thoracic w w/o Contrast 72157
(*) Please bring medical ID card to appointment.
(Please Print)
Fax order to 501-614-7509
RAPA accepts most majorinsurance plans, includingBlue Cross Blue Shieldproducts, Aetna, Cigna, UnitedHealth Care and QualChoiceQCA. Prior authorization is required by most commercialinsurance companies. Pleasepreauthorize before schedulingprocedure.
Pumps (Infusion, Insulin, Chemotherapy)*Aneurysm Clip or Surgery* Prosthetic Heart Valve*
Middle Ear Prosthesis (Cochlear Implant)*
Other: _____________________Left / Right, Bilat, w/o, w & w/o
501-686-2621
MR/Arthrogram 73222 Shoulder OR Wrist OR Elbow Left / Right
MR/Arthrogram 73722 Hip OR Knee - Left / Right
Cell Phone Number
CDSM HCPCS Code** AUC Modifier**
**Required for Medicare Payment Only
