Last year, AmeriHealth introduced a new utilization management program for genetic/genomic tests, certain molecular analyses, and cytogenetic tests for all AmeriHealth members. We are working with CareCore National, LLC d/b/a eviCore healthcare (eviCore) to manage precertification and/or prepayment coverage reviews for these tests.
Please note that the ordering provider is responsible for submitting precertification requests for the applicable tests. Failure to adhere to the precertification process may result in your AmeriHealth patients receiving a bill for the testing.
Important information for laboratories
When a request for genetic/genomic testing is received, laboratories must ensure a precertification is on file before rendering services. If a precertification is not on file for the member, it is the laboratory?s responsibility to submit a precertification request to eviCore.
You can access the Prior Authorization Procedure Lists for AmeriHealth New Jersey and AmeriHealth Pennsylvania on eviCore?s website.
Submitting requests to eviCore
You can initiate precertification for genetic/genomic tests in one of the following ways:
- NaviNet® web portal. Select CareCore from the Authorizations option in the AmeriHealth Workflows menu.
- Telephone. Call eviCore directly at 1-866-686-2649.
Prepayment review
All genetic/genomic tests, along with certain molecular analyses and cytogenetic tests, are reviewed by eviCore prior to final claim adjudication and payment (if applicable). 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 #06.02.52d: 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 uses 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, call Customer Service at 1-888-YOUR-AH1 for AmeriHealth New Jersey or at
1-800-275-2583 for AmeriHealth Pennsylvania.
*This list of services is subject to change.
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