Radiology/Imaging Program Update: PA/MND Review to be required for Out-of-Network Facilities/Sites
Horizon BCBSNJ collaborates with eviCore healthcare to manage prior authorization and medical necessity determination (PA/MND) review of advanced imaging services through our Radiology/Imaging Services program.
Historically, PA/MND reviews have been performed when advanced imaging services are coordinated at Horizon BCBSNJ participating sites/facilities.
Effective April 1, 2021, eviCore will also perform PA/MND reviews for advanced imaging services to be performed at facilities/sites that DO NOT participate with Horizon BCBSNJ. This change will help ensure standards of safety and care are uniformly applied to Horizon BCBSNJ’s members regardless of where services are rendered. PA/MND review is required for members enrolled in insured Horizon HMO, Horizon POS, Horizon Direct Access, Horizon PPO, Horizon EPO, Horizon Medicare Advantage and NJ DIRECT plans. PA/MND reviews do not apply to radiology/imaging services rendered during ER visits or inpatient stays.
This program update will apply to members included in the scope of the Radiology/Imaging Services program who are enrolled in plans that include out-of-network benefits when advanced imaging services are coordinated at rendering sites within Horizon BCBSNJ’s local service area. This includes all New Jersey counties, the counties in Delaware, New York and Pennsylvania that are contiguous to New Jersey, and Lehigh County, PA. Members that do not have out-of-network benefits will continue to be directed to coordinate care at participating sites within Horizon BCBSNJ’s network.
To verify if a PA/MND review is required, visit eviCore.com. You may also call eviCore at 1-866-496-6200, weekdays, between 7 a.m. and 7 p.m., Eastern Time (ET), and Saturday and Sunday, between 9 a.m. and 5 p.m., ET.