The Advanced Imaging Services included in this program are CT/CTA, MRI/MRA, PET and Nuclear Medicine studies (including Nuclear Cardiology).
You should check eligibility and benefits prior to performing any services related to this program
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.
- Radiology/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 radiology imaging services
- Contrast Agents and Radiopharmaceuticals
- Medical Information Requirements
- Prior Authorization Procedure Search Tool
ANNOUNCEMENTS / UPDATES
- Maternal Fetal Medicine Evaluation Coding
- Radiology/Imaging Guidelines for Emergency Room Preliminary Reads (Wet Reads)
- 72 Hour Rule
- Modifier 26
- Modifier 59
- Modifier 76
FIRST LEVEL UTILIZATION MANAGEMENT (UM) APPEALS
Fax first level UM appeals for Horizon Medicare Advantage and Braven Health Medicare Advantage members to 1-609-583-3028 or mail to:Braven Health Medical Appeals PO Box 10195 Newark, NJ 07101 Horizon Medicare Advantage Medical Appeals PO Box 10195 Newark, NJ 07101
Fax first level UM appeals for Horizon fully insured commercial and ASO members to 1-866-699-8128 or mail to:eviCore healthcare Attn: Clinical Appeals Mail Stop 600 400 Buckwalter Place Blvd Bluffton, SC 29910
eviCore healthcare also manages Advanced 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.