Radiation Therapy Program Questions and Answers
Horizon Blue Cross Blue Shield of New Jersey collaborates with eviCore healthcare to administer our Radiation Therapy program. Through this pre-service Medical Necessity Determination (MND) program, eviCore helps us 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.
Q1. When was the Radiation Therapy Medical Necessity Determination (MND) program effective?
A1. Our Radiation Therapy program was effective February 18, 2009.
Q2. What cancer types require a MND as part of the Radiation Therapy Program?
A2. As part of the Radiation Therapy Program, MND should be requested from eviCore for all cancers as well as for non-cancerous conditions that require radiation treatment including, but not limited to, the following:
- Adrenal Cancer
- Anal Cancer
- Bile Duct Cancer
- Bladder Cancer
- Bone Metastases
- Brain Metastases
- Breast Cancer
- Cervical Cancer
- Endometrial Cancer
- Esophagus Cancer
- Extracranial Oligometastases
- Gallbladder Cancer
- Gastric Cancer
- Head/Neck Cancer
- Hepatobiliary Cancer
- Hodgkin's Lymphoma
- Kidney Cancer
- Liver Cancer
- Multiple Myeloma
- Non-Cancerous Diagnosis
- Non-Hodgkin's Lymphoma
- Non-Small Cell Lung Cancer
- Other Metastases (Non-Bone/Brain)
- Pancreatic Cancer
- Primary Central Nervous System Lymphoma
- Primary Central Nervous System Neoplasms
- Prostate Cancer
- Rectal Cancer
- Skin Cancer
- Small Cell Lung Cancer
- Soft Tissue Sarcoma
- Testicular Cancer
- Urethral Cancer
- Vulva Cancer
Q3. Whom do I contact for a Medical Necessity Determination (MND)?
A3. eviCore accepts requests for MNDs related to Radiation Therapy services:
- Online at eviCore.com, or by
- Calling eviCore at 1-866-242-5749
MNDs will be provided at the end of the call if all necessary clinical information has been provided and meets clinical criteria.
Q4. What is the best way to obtain a MND?
A4. The fastest way for physicians to obtain a MND is by visiting eviCore.com. MND decisions can be provided immediately online. You can also request a MND by calling eviCore at 1-866-242-5749.
Q5. Can eviCore issue a MND online?
A5. eviCore will allow physician's to order Radiation Therapy Services and obtain a MND online in real time. Physician's unfamiliar with eviCore's website capabilities can access a training module at eviCore.com or contact an eviCore provider relations representative to request a web training session.
Q6. Which products require a MND?
A6. Providers should obtain pre-service or post-service MND for Horizon fully insured and Level Funding members enrolled in the following plans/products:
- Horizon HMO
- Horizon HMO Access
- Horizon Point of Service (POS)
- Horizon Direct Access
- Horizon Medicare Advantage
- Horizon PPO
- Small group plans
MND is required for Radiation Therapy services for patients enrolled in Horizon NJ Health plans and products. Please visit the Horizon NJ Health eviCore healthcare webpage.
Q7. Which products require a pre-service MND?
A7. Providers must obtain pre-service MND for patients enrolled in Braven Health℠ fully insured and Level Funding plans/products.
Q8. Which products do not require a MND?
A8. At this time, members enrolled in self- funded Administration Services Only (ASO) groups are not included. If in the future, the employer group decides to participate they would be added.
- ASO groups (unless the groups have opted-in to the program)
- State Health Benefit Program (SHBP)/School Employees' Health Plan Benefits Program (SHEBP)
- Federal Employee Program® (FEP®)
- If we are the secondary payer (COB and Medicare supplemental)
- Out-of-state Blues Plans
Q9. What information is required, from the physician, for an MND?
A9. eviCore requires the following information to complete an MND:
- Cancer type being treated with radiation therapy
- Patient Information
- Ordering Provider information
- Rendering Site information
- A completed worksheet* specific to the diagnosis
- Radiation Oncologist's consultation notes (only if the MND is not immediately approved)
* Provider worksheets specific to each cancer type are available at eviCore.com. These worksheets list all clinical questions that will be asked of the provider during the initial Medical Necessity review either online or by phone. If there is not a specific worksheet for your patient's diagnosis, please use the “Other Cancers” worksheet.
Q10. What will an MND authorize?
A10. One MND will be assigned per treatment plan.
Q11. What is the format of a MND number?
A11. The MND should be formatted as with:
- One (1) alpha
- Nine (9) numerics
- For example: A000011111
Q12. How can I verify if a MND number has been assigned to a MND request?
A12. Visit eviCore.com and click Authorization Lookup.
Q13. Can a MND number expire?
A13. Yes, visit eviCore.com for expiration dates and click on Authorization Lookup.
Q14. Which place of service requires MND?
A14. All participating and non-participating professional (office and outpatient) and outpatient institutional claims are included.
Q15. If administering the treatment plan in an outpatient hospital setting, is an MND required?
A15. Yes, MNDs are required for members with plans/products included in the program.
Q16. Will urgent requests be accepted?
A16. Yes, urgent requests will be accepted and a determination expedited if clinically indicated. Urgent cases for Commercial plans/products are handled within 24 hours of receipt of all necessary clinical information. Urgent cases for Medicare Advantage plans/products are handled no later than 72 hours after receipt of request.
Q17. How soon can I submit a request for a MND?
A17. A MND request may be made for up to two weeks prior to the planned administration of the treatment plan.
Q18. How quickly will a MND be provided?
A18. Determinations for Commercial plans./products will be made as soon as possible, but no later than three business days from the receipt of all required clinical information. Determinations for Medicare Advantage will be made as soon as possible, but no later than 14 Calendar days after receipt of the request.
Q19. Can a health care professional discuss an adverse benefit determination made by eviCore?
A19. Yes, A health care professional may call the eviCore Peer to Peer Consultation line 1-866-241-6603 to discuss an adverse benefit determination made by eviCore for a patient enrolled in a Horizon fully insured commercial plan or Administrative Services Only employer group plan with an eviCore medical director.
Q20. How can I appeal an adverse benefit determination made by eviCore?
A20. To appeal an adverse benefit determination made by eviCore for Horizon Medicare Advantage or Braven Health℠ Medicare Advantage members you may fax a request to Horizon at 1-609-583-3028 or mail a request to:
Braven Health Medical Appeals
PO Box 10195
Newark, NJ 07101
Horizon Medicare Advantage Medical Appeals
PO Box 10195
Newark, NJ 07101
To appeal an adverse benefit determination made by eviCore for Horizon fully insured commercial or Administrative Services Only employer group plans you may fax a request to eviCore at 1-866-699-8128 or mail a request to:
Attn: Clinical Appeals Mail Stop 600
400 Buckwalter Place Blvd
Bluffton, SC 29910
Q21. If calling eviCore to request an AIS can a request for a MND for Radiation Therapy be made at the same time?
A21. Yes, you can alert the Clinical Reviewer that you wish to initiate a MND for the Radiation Therapy program at the completion of your Advanced Imaging review.
Q22. What is eviCore's Customer Service number for the Horizon Radiation Therapy Program?
A22. Dial 1-866-242-5749 and select the Customer Service menu option.
Q23. What if a MND is NOT obtained?
A23. While obtaining a pre-service MND is voluntary, if you do not do so, your claim will be denied pending a post-service medical necessity review to determine medical necessity.
This post-service medical necessity review will be conducted by eviCore applying the same medical policies referenced above. The requesting time limit for an MND is 18 months from the date of service.
Q24. What if a claim has been denied?
A24. A claim can deny for different reasons. Please look at the denial reason code and description on the explanation of benefits to see which company to contact.
If your claim has been denied due to lack of a MND and you have not contacted eviCore for a MND, immediately call eviCore and submit the request. If your request does not demonstrate Medical Necessity, you will be notified in writing. This notice will provide detailed instruction for submitting clinical appeals.
If your claim has been denied due to eligibility, provider/site participation or other benefit plan-related issue, please call Horizon at 1-800-624-1110.
If you are having problems with getting Radiation Therapy claims reimbursed, call eviCore Customer Service at 1-866-242-5749.
Q25. What is a partial approval notice?
A25. This document will inform the provider of approved and non-approved services for the requested treatment plan. It will also contain clinical appeal information.
If you received a partial approval, you will need to submit additional clinical information to eviCore for the remainder of the treatment plan.
Q26. Will the criteria used to make a MND for the Radiation Therapy program be available for review?
A26. Yes, go to eviCore.com under the Radiation Therapy section to view these criteria and Horizon Medical Policy. Horizon Medical Policy is always available on HorizonBlue.com/medicalpolicy.
Q27. If a member changes referring providers or site of service will a new MND be required?
A27. No, a new MND is not required.
Q28. Medical Necessity Determination Forms:
A28. For this program there are no Medical Necessity Determination fax request forms. Requests must be submitted on the web or by phone. Worksheets specific to each managed cancer type are available on eviCore's website in the Provider Resource area. These forms will assist the physician ordering the radiation therapy treatment in outlining the clinical and treatment plan information that will be required when submitting a MND.
Q29. Is a new MND required if the patient requires additional treatment (such as a recurrence of disease or change in patient clinical condition)?
A29. Yes. The MND is valid for the treatment plan that has been requested by the physician. If the physician provides the member with another episode of care a new MND will be required.
If during a course of treatment the physician intends to modify an approved treatment plan, he/she should call an eviCore medical director to discuss the new treatment plan to allow the existing MND to be adjusted appropriately. The modifications to the treatment plan that are determined to be medically necessary will be communicated during the physician to physician call.
Q30. Can a MND be obtained for multiple sites of therapy for the same patient at the s ame time?
A30. Yes, when medically necessary.
Q31. Who is responsible for obtaining a MND?
A31. The radiation oncologist/referring physician who has determined the type of radiation therapy treatment the patient should obtain the MND.
Q32. Are chemotherapy drugs included in this program?
A32. No, this program only addresses radiation therapy treatment.
Q33. If the patient begins radiation therapy treatment with one radiation therapy facility and decides to change facilities (different TIN) during a course of treatment, is a new MND required?
A33. Yes. If the patient is seeing a new physician that is part of a different practice, a new treatment plan will be devised and a new MND must be issued to the physician.
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