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Our Imaging & Specialty Partner: eviCore

Radiology
eviCore healthcare manages Advanced Imaging Services for our members through Prior Authorizations/Medical Necessity Determinations (PA/MND) with physicians. eviCore healthcare helps to ensure our members receive appropriate radiology/imaging services, provides clinical consultation to our participating healthcare professionals and assists in the scheduling of radiology/imaging services. The Advanced Imaging Services included in this program are CT/CTA, MRI/MRA, PET and Nuclear Medicine studies (including Nuclear Cardiology).

Cardiology
eviCore healthcare administers our Cardiology Imaging program by using evidence-based criteria. They ensure requests for advanced cardiac imaging meet quality standards recommended by organizations such as the American College of Cardiology, the American Heart Association and the Heart Rhythm Society and identify the most appropriate cardiac imaging study based on the patient’s medical and prior imaging history.

Pain Management
eviCore healthcare administers a Prior Authorization/Medical Necessity Determinations(PA/MND) program for Pain Management providers. The Horizon BCBSNJ Medical Policies on pain management were developed using recognized evidence based guidelines and incorporate criteria derived from published materials that are supported by nationally recognized agencies such as the American Society of Interventional Pain Physicians, the American Pain Society, the American Academy of Pain Management and the National Institutes of Health.

Radiation Therapy
eviCore healthcare implements our Pre-service Medical Necessity Determination (MND) program. This program helps ensure that the radiation therapy services provided to our members are consistent with nationally recognized clinical standards. The Radiation Therapy program addresses a patient’s specific disease state, stage and treatment goals and offers clinicians the necessary flexibility to render appropriate quality care in a timely manner.

Oncology
eviCore healthcare administers a program to assist in the medical necessity determination (MND) of the new and expensive treatments that are available to cancer patients. These drugs are subject to various applications and protocols. Therefore, implementation of a program to assist the member and provider is crucial to ensuring appropriate utilization and tracking of these drugs. The program was designed and overseen by board-certified hematologists and oncologists.

The program utilizes evidence based clinical pathways to determine appropriate plans of care and appropriate application of drugs related to this program. In addition, specific reimbursement methodologies, policies, procedures and tracking have been instituted. Listed below are the three injectable medications used to stimulate red blood cell production and are the basis for the Erythropoeitin Stimulating Agents (ESA) Medical Necessity Determination (MND) program:

  • Aranesp (Darbepoetin Alpha)
  • Epogen (Epoetin Alpha)
  • Procrit (Epoetin Alpha)