Cardiology Imaging Program

Horizon Blue Cross Blue Shield of New Jersey has partnered with eviCore healthcare to administer our Cardiology Imaging program by using evidence-based criteria and ensuring 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 identifying the most appropriate cardiac imaging study based on the patient's medical and prior imaging history.

Please note that eligibility and participation may vary based on line of business therefore, all providers should check eligibility and benefits prior to performing any services related to this program. In addition, actual benefit determinations cannot be made until a claim is received and is subject to the provisions of the patient's present contract including any applicable deductible, coinsurance and/or coordination of benefits. Payment is dependent on the patient being an eligible Horizon BCBSNJ member at the time the services are rendered. Authorizations will be affected should the claim submitted differ from the information provided at the time of a request.

PA/MND REVIEW FOR OUT-OF-NETWORK SITES/FACILITIES

As part of this program eviCore also performs PA/MND reviews for services that are to be performed at facilities/sites that DO NOT participate with Horizon if:

• The nonparticipating facility/site is physically located within New Jersey
• Services are to be provided to patients enrolled in a Horizon or Braven Health plan that includes out-of-network benefits.

Members that do not have out-of-network benefits will continue to be directed to coordinate care at participating sites within Horizon's networks.

RESOURCES

• Cardiology Imaging Program Q&A
• Cardiology Imaging Services subject to PA/MND as part of this program
• Code Bundling Rules
• Code Pair Rules Bank
• Review our Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities administrative policy.
• Review our Diagnostic Imaging Privileging Policy to identify the accreditation required for practitioners and facilities to render and receive PA/MND approvals for cardiology imaging services
• Contrast Agents and Radiopharmaceuticals
• Medical Information Requirements
• eviCore Online Forms & Resources

ANNOUNCEMENTS / UPDATES

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FIRST LEVEL UTILIZATION MANAGEMENT (UM) APPEALS

eviCore healthcare also manages Cardiology Imaging services provided to members enrolled in Horizon NJ Health plans and programs (including Medicaid Managed Care, NJ FamilyCare, Horizon NJ TotalCare (HMO D-SNP) and Managed Long Term Services & Supports (MLTSS). Visit the Horizon NJ Health eviCore healthcare webpage for information.

eviCore healthcare is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the provision of Prior Authorization and/or Medical Necessity Review (PA/MND) of certain nonemergency radiology services.