As of January 1, 2015, precertification is required for non-emergent outpatient radiation therapy services for all commercial AmeriHealth Pennsylvania HMO and POS members. AmeriHealth is working with CareCore National, LLC (CareCore) to manage precertification requests for non-emergent outpatient radiation therapy services. Precertification is not required when radiation therapy is rendered in the inpatient hospital setting. Furthermore, although precertification isn?t required for members ages 19 and under, we will require notification to CareCore for these members to ensure timely and accurate claims payment.

You can initiate precertification for non-emergent outpatient radiation therapy in one of the following ways:

• NaviNet^® web portal. A new option was added within the Authorizations transaction that links to the CareCore provider portal.
• CareCore provider portal. Access the CareCore provider portal directly at www.carecorenational.com. A login and password are required. This login information will be needed every time you request precertification through CareCore. If you already have access to the CareCore provider portal, please use your current login information.
• Telephone. Call CareCore directly at 1-866-686-2649.

Services that require precertification

The following radiation therapy procedures require precertification through CareCore as of January 1, 2015:

• 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);
• 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, with the exception of Ra 223 (Xofigo^®) and immunotherapy using Zevalin^® .

Starting in April 2015, precertification requests for non-emergent outpatient radiation therapy will be reviewed for medical necessity. In addition, proton beam radiation therapy, Ra 223 (Xofigo^®), and immunotherapy using Zevalin^® will require precertification through CareCore. Note: Proton beam radiation therapy and Ra 223 (Xofigo^®) currently require precertification by AmeriHealth. Providers must continue to request precertification for these services by using the Authorizations transaction on NaviNet until March 31, 2015.

For more information

Refer to Medical Policy #09.00.56: Radiation Therapy Services, which is available on our Medical Policy Portal. Select Accept and Go to Medical Policy Online and then the Commercial tab from the top of the page. Type the policy name or number in the Search field. You can also view policy activity through NaviNet by selecting the Reference Tools transaction, then Medical Policy.

Note: This precertification requirement does not apply to AmeriHealth New Jersey commercial HMO and PPO or Medicare Advantage HMO members.

AIM is contracted with AmeriHealth to perform precertification for select services for most managed care members.

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