Additional training session
eviCore will host the following tutorial webinar to assist you in using
their portal to request precertification for non-emergent outpatient radiation
therapy services:
- Wednesday, January 20, 2016, at 2 p.m.
If you are interested in participating, send us your contact information via
email.
As of January 1, 2016, precertification for non-emergent outpatient
radiation therapy services for all commercial and Medicare Advantage
AmeriHealth New Jersey members is required. AmeriHealth New Jersey is working
with CareCore National, LLC d/b/a eviCore healthcare (eviCore), a specialty
benefit management company, to manage precertification requests for
non-emergent outpatient radiation therapy services.
Services that require precertification
Ordering physicians must contact eviCore to obtain precertification for
elective, non-emergent outpatient radiation therapy services. Below is a list
of radiation therapy services that require precertification*:
- external beam, including 2D, 3D conformal, intensity-modulated radiation
therapy (IMRT), tomotherapy, image-guided radiation therapy (IGRT),
stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery
(SRS);
- proton beam radiation therapy;
- brachytherapy, including low-dose rate (LDR), high-dose rate (HDR), and
outpatient intra-operative techniques (IORT);
- hyperthermia;
- neutron radiotherapy;
- radio-labeled drugs used for radiation therapy (e.g., Radium Ra 223
dichloride [Xofigo®], ibritumomab tiuxetan
[Zevalin®]).
*This list of services is subject to change.
Be sure to verify precertification requirements at the time of service.
Please note that for members under the age of 19, services requested will be
automatically approved; however, precertification through eviCore is still
required to ensure accurate and timely claims payment.
As a reminder, precertification requests for all high-technology diagnostic
imaging services (e.g., CT, MRI, PET) continue to be handled through the
current process by AIM Specialty Health®.
Precertification guidelines
The AmeriHealth criteria used as the basis for reviewing precertification
requests are available on eviCore?s website.
In addition, the following medical policies include a link to the criteria
that eviCore uses to determine medical necessity for radiation therapy services
as well as a complete list of procedure codes that require
precertification:
- Commercial: #09.00.56b: Radiation Therapy Services;
- Medicare Advantage: #MA09.020b: Radiation Therapy Services.
To view these policies, visit our Medical Policy Portal. Select Accept and Go to Medical
Policy Online, and then select the Commercial or Medicare
Advantage tab from the top of the page, depending on the version of the
policy you?d like to view, and then type the policy name or number in the
Search field.
Requesting precertification
Use the NaviNet® web portal to initiate precertification for
non-emergent outpatient radiation therapy. Select eviCore/CareCore from
the Authorizations option in the Workflows menu, and a new window will open
that sends providers directly to eviCore?s provider portal and initiates the
precertification process. Once on eviCore?s portal, you will be required to
create a login and password. This login 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.
You can also request precertification by calling eviCore directly at
1-866-686-2649.
For more information
If you have questions about these new precertification requirements,
contact your Provider Partnership Associate, call Customer Service at
1-888-YOUR-AH1 (1-888-968-7241), or call eviCore at
1-866-686-2649.
NaviNet is a registered trademark of NaviNet, Inc.
AIM is contracted with AmeriHealth to perform
precertification for select services for most managed care members.