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Radiology/Imaging Services Utilization Management Program Expands to Include Certain Ultrasound Procedures

The program described in this news item has been indefinitely suspended. Review the most current information.


Beginning May 1, 2019, Horizon Blue Cross Blue Shield of New Jersey will expand its advanced Radiology/Imaging Services utilization management program to include certain obstetrical and non-obstetrical ultrasound procedures.

Through this expanded program, Horizon BCBSNJ will collaborate with eviCore healthcare (eviCore) to conduct Medical Necessity Determination (MND) reviews, according to Horizon BCBSNJ’s Medical Policy guidelines and criteria, of ultrasound services to be provided to members enrolled in Horizon BCBSNJ fully insured and Medicare Advantage products and plans. Ultrasound services rendered in the inpatient setting, observation setting or the Emergency Room (ER) are not subject to MND as part of this program.

Members enrolled in self-insured ASO (Administrative Services Only) employer groups, the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP), the Federal Employee Program® (FEP®), Horizon NJ Health or Horizon NJ TotalCare (HMO SNP) are not included in this program expansion.

MND Review for ultrasounds
Referring physicians are strongly encouraged to obtain a pre-service MND for the ultrasound procedures specified on the enclosed list. Obtaining a pre-service MND helps expedite claims processing and may not require the submission of medical records. eviCore will conduct reviews of ultrasound services to:

  • Determine medical necessity;
  • Help reduce unnecessary tests/procedures; and,
  • Help members get the most out of their plan benefits.

eviCore will not perform member scheduling for ultrasound services.

Participating Primary Care Physicians, specialty physicians and other health care professionals must also be properly accredited under Horizon BCBSNJ’s privileging policy guidelines to receive pre-service MND approvals for ultrasound services they are privileged to perform in an office setting.

Ultrasound requests will follow slightly different processes as outlined below.

Obstetrical ultrasounds

eviCore will not conduct MND review for the first two ultrasounds for any pregnancy. There is no need to submit a request to eviCore for the first two ultrasounds. Physicians should submit a request for eviCore to perform MND if three or more ultrasounds are required for a pregnancy, or if the maternal or fetal condition changes.

If the pregnancy is considered to be high risk, additional ultrasounds or units of ultrasounds may be approved based on the clinical scenario and clinical guidelines.

Non-Obstetrical ultrasounds
Physicians should submit a request for eviCore to perform MND for ALL non-obstetrical services.

How to Obtain MND
Requests for pre-service MND can be made online or by phone. To obtain a determination from eviCore, referring physicians should:

  • Submit a request on eviCore.com; or
  • Call eviCore at 1-866-496-6200, Monday through Friday, between 7 a.m. and 7 p.m., Eastern Time (ET), and Saturday and Sunday, between 9 a.m. and 5 p.m., ET.

How to validate pre-service MND was obtained
Rendering health care professionals and facilities are able to validate that a pre-service determination was requested and approved by visiting eviCore.com or by calling eviCore at 1-866-496-6200. Claims submitted for obstetrical and non-obstetrical services for which pre-service MND was not obtained will be denied pending receipt of information for eviCore to perform a post-service MND review. Ultrasound services reviewed by eviCore on a post-service basis and deemed not medically necessary may not be eligible for coverage or payment by Horizon BCBSNJ.

Horizon BCBSNJ Guidelines
You can review the established medical policy criteria and guidelines that eviCore will follow when determining medical necessity for ultrasound services. Visit HorizonBlue.com/radiologyimaging to access the following:

Verifying Member Benefits
Your staff may look at the back of the member’s ID card to determine whether the plan is self-insured Administrative Services Only (ASO) or fully insured. A self-insured ASO member ID card will state, “Horizon BCBSNJ provides administrative services only and does not assume any financial risk for claims.” A fully insured member’s ID card will not have that message. Please always verify member benefits, as it may be possible that the most current ID card is not presented at the time of service.

Questions?
Horizon BCBSNJ values your participation in our network and the care you provide to our members. If you have any questions, contact your Network Specialist or Institutional Services Representative.

Published on: February 1, 2019, 02:12 a.m. ET
Last updated on: January 8, 2020, 03:42 a.m. ET