​Utilization management program – eviCore®

Precertification has been delegated to CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company, for:

  • Genetic/genomic tests, certain molecular analyses, and cytogenetic tests
  • Radiation therapy

Genetic/genomic tests, certain molecular analyses, and cytogenetic tests

 

Precertification for certain genetic/genomic tests is required through eviCore for all commercial members.

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 Independence patients receiving a bill for the testing.

For laboratory providers: 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.

In addition, eviCore manages prepayment review for all genetic/genomic tests, along with certain molecular analyses and cytogenetic tests, for all commercial members.

Policy and guidelines

 

For additional information on this utilization management program, please refer to the medical policy on our Medical Policy Portal:

    Commercial: #06.02.52: eviCore Lab Management Program

Radiation therapy

 

Precertification for nonemergent outpatient radiation therapy services is required through eviCore for all commercial and Medicare Advantage members. Precertification is not required when radiation therapy is rendered in the inpatient hospital setting.

Independence’s Radiation Treatment of Breast Carcinoma guideline indicates that a hypofractionated regimen is the preferred treatment for patients with early stage (T1-2N0) breast carcinoma who meet certain criteria. For these patients, a request for precertification of conventional fractionation will require a peer-to-peer call with an eviCore Radiation Oncologist.

Policies and guidelines

 

For additional information on this utilization management program, please refer to the medical policies on our Medical Policy Portal:

  • Commercial: #09.00.56: Radiation Therapy Services
  • Medicare Advantage: #MA09.020: Radiation Therapy Services

For more information

 

Please refer to the Clinical Services – Utilization Management or the Specialty Programs sections of the Provider Manual for Participating Profession Providers for more information on eviCore.

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