Tufts Health Plan covers medically necessary imaging services performed by the same provider on the same member, within the same visit in a Tufts Health Plan contracted facility. Tufts Health Plan has consolidated 11 advanced imaging procedure families into one category. When more than one of the imaging services in the same category from the list below is performed, the procedure with the highest allowed amount will be compensated at 100% of the Tufts Health Plan compensation rate and the subsequent procedure(s) will be compensated at 50% of the Tufts Health Plan compensation rate. In the event that a procedure code listed in the table below is submitted with a procedure code from another category or not subject to reduction logic, each procedure will be priced at 100% of the Tufts Health Plan compensation rate. This methodology applies to claims submitted for the technical (performance of the imaging service) or global (performance and interpretation) component of an
imaging procedure.
Note: Compensation for imaging services is based on a provider’s specialty and privileging requirements assigned by Tufts Health Plan. Tufts Health Plan’s Imaging Privileging Committee must privilege providers who are not radiologists, in order for the provider to be eligible for compensation. The specialties listed in the last column are the only providers eligible for compensation by Tufts
Health Plan for the procedure codes listed.
Category 1 Procedures Code Combinations Provider Specialty
CT and CTA MRA and MRI Nonobstetrical ultrasound
70336, 70450, 70460, 70470, 70480, 70481,
70482, 70486, 70487, 70488, 70490, 70491,
70492, 70496, 70498, 70540, 70542, 70543,
70544, 70545, 70546, 70547, 70548, 70549,
70551, 70552, 70553, 70554, 71250, 71260,
71270, 71275, 71550, 71551, 71552, 71555,
72125, 72126, 72127, 72128, 72129, 72130,
72131, 72132, 72133, 72141, 72142, 72146,
72147, 72148, 72149, 72156, 72157, 72158,
72159, 72191, 72192, 72193, 72194, 72195,
72196, 72197, 72198, 73200, 73201, 73202,
73206, 73218, 73219, 73220, 73221, 73222,
73223, 73225*, 73700, 73701, 73702, 73706,
73718, 73719, 73720, 73721, 73722, 73723,
73725, 74150, 74160, 74170, 74174, 74175,
74176, 74177, 74178, 74181, 74182, 74183,
74185, 74261, 74262, 75557, 75559, 75561,
75563, 75571, 75572, 75573, 75574, 75635,
76604, 76700, 76705, 76770, 76775, 76776, 76831
76856, 76857, 76870, 77058, 77059, 91200
Radiologist
Ultrasound — Pregnant uterus/pelvic/obstetrical and nonobstetrical
76801,76802, 76805, 76810, 76811, 76812, 76815,
76816, 76817, 76818, 76819, 76830
Radiologist; non-radiologist privileged for OB ultrasound
