Musculoskeletal (MSK) program

Carelon Musculoskeletal, Interventional Pain Management, Cardiology and Radiology

Effective for dates of service on and after Oct. 1, 2024, Dean Health Plan has partnered with Carelon, a utilization management (UM) program vendor, to support the provider submission and medical necessity review process for select musculoskeletal (MSK), interventional pain management, cardiology, and radiology services. Submissions and review by Carelon will replace those previously managed by NIA Magellan. 

The following information applies to the NIA (Evolent) program, for dates of service on or prior to Sept. 30th 2024. Authorizations obtained through NIA (Evolent) will be available for viewing through 12/31/2024.

Dean Health Plan works with National Imaging Associates (NIA) (also referred to as Magellan Healthcare) for review and authorization of our Musculoskeletal (MSK) Care Management Program. This includes prior authorization by the treating physician for non-emergent inpatient and outpatient musculoskeletal surgeries, specifically hip, knee, shoulder, lumbar, and cervical spine.

This program incorporates the following key components:

  • The MSK Care Management Program applies to the following Dean Health Plan product lines:
    • Commercial – Dean HMO
    • Dean POS 
    • Dean PPO 
    • Dean Focus EPO 
    • Dean Administrative Services Only (ASO) 
    • Dean Advantage
    • Dean BadgerCare Plus (Medicaid)
  • NIA's MSK Care Management Program manages the medical necessity review for non-emergent inpatient and outpatient musculoskeletal surgeries through physician authorization, prior to performing the surgery.
  • Members who require the services of a provider who is not a Dean Health Plan Network provider may require two authorizations. The initial authorization will need to be obtained for the use of the non-network provider via Dean Health Plan Utilization Management Department.
  • Authorization for these procedures may be submitted through NIA's website www1.RadMD.com or the NIA's toll-free phone number at 866-307-9729.
  • MSK surgeries included in this program are non-emergent hip, knee, shoulder, lumbar, and cervical spine surgeries. A list of current spine surgery and knee, hip, and shoulder surgery CPT codes can be found in the Additional MSK Resources section.

Member services

For questions, contact NIA's customer service representatives: 1-866-307-9729, available 7 a.m. - 7 p.m. CT, Monday - Friday.