AmeriHealth Administrators to delegate some precertification to eviCore

Home

Administrative

Billing & Reimbursement

TitleWeb
AmeriHealth Administrators to delegate some precertification to eviCore

January 28, 2021

This article was revised on January 28, 2021, to update the program’s policy information.

Beginning April 1, 2021, AmeriHealth Administrators will delegate precertification for certain services to eviCore healthcare (eviCore).

Providers should seek precertification from eviCore for:

certain genetic/genomic tests (i.e., nucleic acid testing) and certain molecular analyses;
radiation therapy.

Certain genetic/genomic tests and molecular analyses

Precertification for certain genetic/genomic tests (i.e., nucleic acid testing) and molecular analyses is required through eviCore.

The ordering provider is responsible for submitting precertification requests for the applicable tests. Failure to adhere to the precertification process may result in a bill to your patient.

When a request for genetic/genomic testing is received, laboratories must ensure a precertification is on file before rendering services. If precertification is not on file for the member, it is the laboratory’s responsibility to submit a request to eviCore.

Policy and guidelines

For additional information on this utilization management program, please refer to Medical Policy #06.02.52s: eviCore Lab Management. Effective April 1, 2021, this policy may be applicable to plans administered by AmeriHealth Administrators.

Radiation therapy

Precertification for nonemergent outpatient radiation therapy services is required through eviCore. Precertification is not required when radiation therapy is rendered in the inpatient hospital setting.

Consistent with the updated NCCN Guidelines, eviCore has updated their Guidelines to consider hypofractionation medically necessary for specific populations. The Guidelines will no longer consider conventional fractionation medically necessary for these indications.

A request for precertification for conventional fractionation may require a peer-to-peer call with an eviCore Radiation Oncologist.

Policy and guidelines

For additional information on this utilization management program, please refer to Medical Policy #09.00.56k: Radiation Therapy Services. Effective April 1, 2021, this policy may be applicable to plans administered by AmeriHealth Administrators.