As previously communicated, providers are required to obtain precertification through CareCore National, LLC (CareCore) for non-emergent outpatient radiation therapy services for all commercial AmeriHealth Pennsylvania HMO and POS members. For members under age 19, services requested will be automatically approved. However, precertification through CareCore is still required to ensure accurate and timely claims payment.

Beginning May 1, 2015, AmeriHealth will transition to the use of CareCore Radiation Therapy Criteria related to outpatient radiation therapy services. In addition, AmeriHealth will delegate precertification for proton beam radiation therapy, radium Ra 223 dichloride (Xofigo^®), and immunotherapy using Zevalin^® to CareCore. Note: Proton beam radiation therapy and radium Ra 223 dichloride (Xofigo^®) currently require precertification by AmeriHealth. Providers must continue to request precertification for these services using the Authorizations transaction on the NaviNet^® web portal until April 30, 2015.

Note: Precertification is not required when radiation therapy is rendered in the inpatient hospital setting. Also, these precertification requirements do not apply to AmeriHealth New Jersey commercial HMO and PPO, Medicare Advantage HMO, Comprehensive Major Medical, or AmeriHealth Medigap members.

Precertification guidelines

The criteria that will be used as the basis for reviewing precertification requests as of May 1, 2015, are available on the Radiation Therapy Tools and Criteria page at CareCore's website.

In addition, Medical Policy #09.00.56: Radiation Therapy Services includes a link to the criteria that CareCore will use to determine medical necessity for radiation therapy services as well as a complete list of procedure codes that require precertification. To view this policy, visit our Medical Policy portal. Select Accept and Go to Medical Policy Online, and then select the Commercial tab from the top of the page. Then type the policy number in the Search field.

Requesting precertification

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

• NaviNet. Select CareCore from the Authorizations transaction.
• CareCore provider portal. Access the CareCore provider portal directly. 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.

Precertification for high–technology diagnostic imaging services

Precertification requests for all high–technology diagnostic imaging services (e.g., CT, MRI, PET) will continue to be handled by AIM Specialty Health^® (AIM), through the current process.

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