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AmeriHealth has introduced a new utilization management program for
genetic/genomic tests, certain molecular analyses, and cytogenetic tests for
all commercial AmeriHealth members. We are working with CareCore National, LLC
d/b/a eviCore healthcare (eviCore) to manage precertification and/or prepayment
reviews.
Precertification requirements
For dates of service on or after July 1, 2016, ordering health care
providers and/or laboratories must contact eviCore to obtain precertification
for certain genetic/genomic tests, including, but not limited to, the
following:*
- BRCA gene testing
- genetic panels and cancer gene expression tests
- genome-wide tests
- pharmacogenomic tests
Submitting requests to eviCore
You can request precertification for genetic/genomic tests for dates of
service on or after July 1, 2016, by calling eviCore directly at
1-866-686-2649 or submitting requests via the NaviNet®
web portal.
To submit a request on NaviNet, select CareCore from the
Authorizations option in the Workflows menu, and a new window will open that
sends providers directly to eviCore's provider portal to initiate the
precertification process. Once on eviCore's portal, you will be required to
create a login and password, which will be used every time you request
precertification through eviCore. If you have already established credentials
for eviCore's portal, please use your current login information.
Prepayment review
For dates of service on or after July 1, 2016, all genetic/genomic
tests, along with certain molecular analyses and cytogenetic tests, will be
reviewed by eviCore. Examples of molecular analyses and cytogenetic tests
include, but are not limited to, the following:*
- comparative genomic hybridization (CGH)
- flow cytometry
- fluorescent in situ hybridization (FISH)
- immunohistochemistry (IHC)
- morphometric analyses
Lab management policy and guidelines
Review Medical Policy #06.02.52: eviCore Lab Management Program for more
information about the utilization management program. The policy includes a
link to the Lab Management Program Clinical Guidelines that eviCore will
use during the precertification and prepayment review processes, as well as a
listing of procedure codes requiring precertification and/or prepayment
review.
To view this policy, visit our Medical Policy Portal. Select Accept and Go to Medical
Policy Online, then select the Commercial tab from the top of the
page and type the policy name or number in the Search field.
More information
If you have questions about any of these requirements, you can contact your
Provider Partnership Associate or Network Coordinator or call Customer Service
at 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey or
at 1-800-275-2583 for AmeriHealth Pennsylvania.
*This list of services is subject to
change.
NaviNet is a registered trademark of NaviNet, Inc.
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