Advanced Imaging Prior Authorization Incorporates Site of Care Review

Included in medical plans for fully insured and OptiFlex groups. Not available for self-funded groups.

Advanced imaging utilization is increasing, and the cost is rising faster at outpatient hospital settings than at freestanding imaging centers. A CT or MRI scan typically costs twice as much at an outpatient hospital facility than it does at a freestanding imaging location.

What’s changing?

Starting January 1, 2026, Premera will expand the Radiology Benefit Management (RBM) program to include site of service review. Premera will work with Carelon to redirect CT and MRI scan requests toward lower cost settings, like freestanding imaging centers, when clinically appropriate. In-area providers in Washington state and Alaska will be impacted by this change.

How the site-of-service program works:

• When a provider orders an imaging service, a list of 2 or more freestanding imaging centers within 30 miles of the original site will be displayed for the ordering provider to choose from.
• If the provider has concerns with redirecting to a freestanding imaging center, they can discuss medical necessity concerns in a peer-to-peer phone call.
• If the provider doesn’t agree to redirect to a freestanding imaging center and the service isn’t medically appropriate at an outpatient hospital setting, the authorization will not be approved.
• Providers and members will be notified and receive an explanation about the outcome of the request.