Radiation Therapy Program

Horizon BCBSNJ, in collaboration with eviCore healthcare, has implemented a Pre-service Medical Necessity Determination (MND) program. This program is to help 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.

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.

• Radiation Therapy Program Q&A
• Medical Information Requirements
• eviCore Online Forms & Resources

RESOURCES

• Visit CMS’s National Correct Coding Initiative Edits webpage to review NCCI and MUE claim editing guidelines that eviCore follows in their processing of claims.
• Visit the website of the American Society of Therapeutic Radiologists for information about radiation therapy billing

eviCore healthcare also manages Radiation Therapy 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.