Radiology Imaging Program Questions and Answers

A. eviCore is a specialty benefit management company that manages the quality and use of outpatient diagnostic and cardiac imaging, radiation therapy, pain management, spine surgery and other services. eviCore ensures that every treatment and test is medically necessary and absolutely appropriate for the individual patient.

A. eviCore works with Horizon BCBSNJ to manage the advanced imaging services (AIS) for our members through Prior Authorization/Medical Necessity Determinations (PA/MNDs) with physicians. eviCore helps ensure appropriate radiology/imaging services for our members, provides clinical consultation to our participating health care professionals and assists in the scheduling of radiology/imaging services.

A. The AIS included in this program are:

• CT/CTA scans
• MRI/MRAs
• PET scans
• Nuclear medicine studies, including nuclear cardiology

A. It is the ordering physician's (i.e., Primary Care Physician or specialist) responsibility to contact eviCore to obtain a PA/MND for AIS. eviCore will not accept a request for a PA/MND from the rendering physician. The rendering physician is responsible for verifying the status of PA or MND prior to rendering services. Physicians may check on the status of a PA/MND by visiting eviCore.com, 24 hours a day, seven days a week, or by calling eviCore at 1-866-496-6200, weekdays, between 7 a.m. and 7 p.m., Eastern Time (ET), and Saturday and Sunday, between 9 a.m. and 5 p.m., ET.

A. To verify if a PA/MND is required, visit eviCore.com 24 hours a day, seven days a week. You may also call eviCore at 1-866-496-6200, weekdays, between 7 a.m. and 7 p.m., ET, and Saturday and Sunday, between 9 a.m. and 5 p.m., ET.

A. Ordering providers can upgrade or downgrade a procedure before or after it is performed.

The following categories of requests to change a CPT® code from the ordering provider or the site will be authorized immediately via the CPT Change Tool regardless of if/when the exam was performed, so long as the anatomic (area of the body) part is the same:

• All Computed Tomography (CT) exams: Any contrast change
• Magnetic Resonance Imaging (MRI) exams: Any contrast change
• All requests to change any nuclear study to the nuclear study CPT code including single-photon emission computerized tomography (SPECT)
• All MRI Breast exams:
  • Unilateral to Bilateral (77058 to 77059)
  • Bilateral to Unilateral (77059 to 77058)
• Any change in the range of Positron Emission Tomography (PET) scans (78811, 78812, 78813, 78814, 78815 and 78816)
• Any change in the range of Echo CPT (93303-93308)

A. Through eviCore.com physicians and their office staff have access to the following features:

• Tutorials provide program overviews and processes
• Physician guidelines display current evidence-based recommendations regarding imaging
• Eligibility lookup indicates which members require PA/MND
• Authorization requests allow offices to initiate authorization requests (requires registration)
• Authorization lookup displays the status of authorizations
• Downloadable forms, including fax submission forms

A. General requests for Commercial plans/products will be resolved within three business days, if all necessary clinical information is supplied. General requests for Medicare Advantage plans/products will be resolved no later than 14 calendar days after receipt of the request.

A. Yes. eviCore accommodates medically urgent requests (non-life-threatening requests that can wait up to 24 hours) for PA/MND. 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. Please call eviCore at 1-866-496-6200 with urgent requests. Emergent cases should be directed to the nearest Emergency Room (ER); PA/MND is not required.

A. A PA/MND is required for members enrolled in insured and Level Funding Horizon HMO, Horizon POS, Horizon Direct Access, Horizon PPO, Horizon EPO, Horizon Medicare Advantage and NJ DIRECT plans. PA/MNDs do not apply to radiology/imaging services rendered during ER visits or inpatient stays.

A. Members of self-funded groups only participate in this program if the group opted in to this program. To verify if a PA is required for ASO members, call eviCore at 1-866-496-6200, weekdays, between 7 a.m. and 7 p.m., ET, and Saturday and Sunday, between 9 a.m. and 5 p.m., ET, or visit eviCore.com.

A PA/MND is required for members enrolled in Horizon NJ Health plans products. Please visit the Horizon NJ Health eviCore healthcare webpage.

A. This program does not apply to members for whom Horizon BCBSNJ is the secondary carrier.

A. Members enrolled in the following products are excluded from this program:

• Self-funded ASO groups (unless the groups have opted-into the program)
• Federal Employee Program®(FEP®)
• BlueCard®
• Medigap
• Indemnity

A. 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.

A. 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

or

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:

eviCore healthcare
Attn: Clinical Appeals Mail Stop 600
400 Buckwalter Place Blvd
Bluffton, SC 29910

A. If the radiology facility is located within our local service area and participates with Horizon BCBSNJ, the physician will need to obtain PA/MND from eviCore. Horizon BCBSNJ's local service area includes all New Jersey counties, the counties in Delaware, New York and Pennsylvania that are contiguous to New Jersey, and Lehigh County, PA.

If the radiology facility does not participate with Horizon BCBSNJ, claims are processed against the member's out-of-network benefits (if applicable) or through the BlueCard® program.

A. Yes, for members with out-of-network benefits, authorization should be obtained prior to services being rendered at a non-participating rendering site.

A. The enhanced AIS scheduling process is as follows:

1. The ordering physician's office contacts eviCore to request a PA/MND by either:
   • Submitting a request on eviCore.com (available 24 hours a day, seven days a week)
   • Calling eviCore at 1-866-496-6200, Monday through Friday, between 7 a.m. and 7 p.m., ET, and Saturday and Sunday, between 9 a.m. and 5 p.m., ET
   • Faxing a completed fax submission form to 1-800-637-5204
2. eviCore will ask for relevant clinical information and history, including a completed fax submission form, clinical office notes, consultation reports and previous diagnostic reports.
3. eviCore will contact the member to schedule the procedure at a participating rendering location. When possible, eviCore will conduct a three-way call with the member, eviCore and the rendering location to facilitate the scheduling process. Members may also call eviCore directly at 1-866-969-1234 to schedule the approved procedure. Members will receive a letter from eviCore confirming the scheduled appointment. If the physician calls to start the case on Saturday or Sunday, the office will be advised to have the member call eviCore at 1-866-969-1234 on Monday to schedule the procedure.
4. Once the appointment is scheduled, eviCore will fax a notice to the physician's office. The notice will include the PA/MND confirmation and the location where the imaging services will be performed. A member may call eviCore directly to schedule an appointment.

A. The Scheduling Line is a service provided by eviCore to Horizon BCBSNJ physicians and members to assist in scheduling radiology/imaging procedures for patients. The Scheduling Line improves patient access to imaging services by helping the patient identify the Horizon BCBSNJ participating radiology/imaging facilities that most closely match their needs.

Physicians and members may call eviCore's Scheduling Line at 1-866-969-1234. eviCore's professional scheduling coordinators are available Monday through Friday, between 7 a.m. and 7 p.m., ET, and with fax availability 24 hours a day, seven days a week. eviCore collects basic information, checks eligibility and connects members directly with the facility they select to schedule an appointment. eviCore provides the ordering physician and facility with a fax confirmation of the patient's appointment, along with the unique tracking number.

A. You can obtain fax submission forms at eviCore.com or by calling eviCore at 1-866-496-6200, weekdays, between 7 a.m. and 7 p.m., ET, and Saturday and Sunday, between 9 a.m. and 5 p.m., ET.

A. Yes. Members may choose the facility to provide their radiology services. eviCore will schedule their visit.

A. Ordering physicians should give their patients a completed radiology prescription with instructions to call eviCore. A tracking number is not required if the ordering physician issues a referral for managed care members. PA/MND reviews are still required for AIS (MRI/MRA, CT/CTA, PET scans, nuclear medicine and nuclear cardiology).

A. Members may call eviCore's Scheduling Line at 1-866-969-1234 to schedule a procedure. A tracking number will be issued for all services scheduled through eviCore.

A. The patient should have his or her Horizon BCBSNJ member ID card number and the completed radiology prescription form available to schedule the appointment.

A. Yes, members enrolled in Horizon Direct Access, Horizon PPO or Traditional/Indemnity products do not require a tracking number or referral for non-AIS procedures. However, these members may use the Scheduling Line if they would like.

A. No. Referrals are not required for radiology/imaging services rendered at non-hospital (freestanding) facilities or in the outpatient department of a participating hospital, as long as the services are scheduled through the Scheduling Line. The tracking number replaces the need for a referral for Horizon HMO, Horizon POS and Medicare Advantage patients. PA/MND reviews are still required for AIS (MRI/MRA, CT/CTA, PET scans, nuclear medicine and nuclear cardiology).

A. Our coding logic is based on the Centers for Medicare & Medicaid Services' (CMS) National Correct Coding Initiative (NCCI) and the Deficit Reduction Act of 2005. For more information on Horizon BCBSNJ's coding logic, claim edits and multiple procedure bundling for radiology/imaging services, visit HorizonBlue.com/radiologyimaging and select Radiology/Cardiology Imaging Program Rules Bank.

A. Call eviCore directly at 1-866-496-6200, Monday through Friday, between 7 a.m. and 7 p.m., ET, and Saturday and Sunday, between 9 a.m. and 5 p.m., ET, or you may contact your Network Specialist.