Programs Administered by eviCore healthcare

Horizon BCBSNJ contracts with eviCore healthcare, a nationally recognized, physician-owned management services company, to manage nonemergency radiology services, Advanced Imaging Services (MRI, CT, PET Scans, Nuclear Medicine including Nuclear Cardiology), cardiac imaging services, radiation therapy, pain management services, spine surgery services and molecular and genomic provided to members enrolled in many of the plans we offer.

eviCore healthcare helps ensure that medically necessary and appropriate services are provided to our members. eviCore healthcare also provides clinical consultation and support to participating. physicians and other health care professionals. They help in scheduling Advanced Imaging Services for our members. eviCore health care provides:

• Real-time online authorizations
• Online guidelines, quick reference guides and program documents
• Health plan links, which allow access to real-time data regarding employer group and/or provider activity
• Consumer Information Resource links, which provide valuable information on procedures, as well as, educational tools for members

Services that Require Prior Authorization (PA)/Medical Necessity Determination (MND)
The following services require the referring physician to obtain a PA/MND from eviCore healthcare:

• Radiology/Cardiology services

  – CT/CTA/CCTA scans

  – MRI/MRA

  – PET/CT scans

  – Nuclear medicine studies (including nuclear cardiology)

• Pain Management services
• Radiation Therapy – MND only
• Spine Surgery services

PA/MND through eviCore healthcare is not required:

• Emergency Room visits
• Patients enrolled in:

  – The Federal Employee Program^® (FEP^®)

  – BlueCard^® (out of state) plans

  – Indemnity/Traditional plans

  – Medigap plans

• Members for whom Horizon BCBSNJ is the secondary carrier.

Contact Information:

• Advanced Imaging Services (AIS) – Radiology Program and Cardiac Imaging Program: 1-866-496-6200

• MusculoSkeletal Program (Pain Management and Spine services): 1-866-241-6603
• Radiation Therapy Program: 1-866-242-5749
• Musculoskeletal Program Services (fax): 1-800-649-4548
• Radiation Therapy Program (phone): 1-866-242-5749
• Or, visit eviCore.com

PARTICIPATING RENDERING SITE RESPONSIBILITIES
Participating rendering sites have a responsibility to ensure that the guidelines/protocols of our program are being followed.

• Prior to scheduling a service, the rendering site must validate that a member’s plan requires a PA/MND. To validate that a member’s plan requires a PA/MND, use the Eligibility Lookup feature on eviCore.com or call 1-866-496-6200. If a PA/MND is required and has not been obtained, the service should not be rescheduled and the rendering site must advise the patient to contact the referring physician prior to receiving the service. Once a PA/MND has been obtained the patient can schedule a new appointment for services.
• Prior to rendering services, the rendering site must verify that a PA/MND has been obtained and the site location is accurate. To verify that a PA/MND has been obtained, visit eviCore.com or call 1-866-496-6200. Services provided without a PA/MND in place may result in nonpayment of services. Participating hospitals may not seek payment from the member in these instances. A retroactive utilization review will not be conducted.
• After rendering services, the rendering site must notify eviCore healthcare if there was a change to the procedure performed. Rendering sites must notify eviCore healthcare within two days if a service provided differs from the service indicated on the PA/MND (e.g., if an MRI of the brain without contrast was performed but an MRI of the brain with contrast is indicated on the PA/MND). If services are performed after hours, leave a voice mail message for eviCore healthcare, include patient information and any changes, if applicable.
• All AIS claim submissions, including claims for professional components, for services provided to members enrolled in plans that require PA/MND, must include eviCore healthcare’s PA/MND number.
• Prior authorizations are effective from the clinical approval date only, not from the date of the request.

Actual benefit determination cannot be made until the claim is received and will be subject to the provisions of the patient’s present contract including any applicable deductible, coinsurance and/or coordination of benefits. Reimbursement is dependent on the patient being an eligible Horizon BCBSNJ member at the time the services are incurred. This authorization will be affected should the claim submitted differ from the information provided at the time of this request.

Note: When using eviCore.com, print the screen shot that shows the patient’s eligibility. The information on the screen is the most current eligibility information. eviCore.com does not store past eligibility information.

RADIOLOGY PROGRAM
eviCore healthcare works with Horizon BCBSNJ to manage the radiology services and AIS (CT/CTA/CCTA scans, MRI/MRAs, PET/CT scans, nuclear medicine studies, including nuclear cardiology) provided to our members through prior authorization/medical necessity determinations (PA/MNDs) with the physicians.

• Services provided include:

  – Scheduling of radiology services.

  – Claim correct coding and privileging assistance

For more information, including impacted services, the PA/MND process and FAQs, click here.

MUSCULOSKELETAL PROGRAM
We work with eviCore to administer an enhanced medical management prior authorization program for musculoskeletal pain management and spine surgery services.

• Services provided by eviCore healthcare include:

  – Online prior authorization (PA) program.

   

  – Online resources, including Horizon BCBSNJ’s Medical Policies.

For more information, including impacted services, the PA/MND process and FAQs, click here.

RADIATION THERAPY PROGRAM
eviCore healthcare works with Horizon BCBSNJ to help coordinate the radiation therapy services provided to Horizon BCBSNJ members who are diagnosed with cancer. eviCore healthcare works with the treating radiation oncologist and review his or her treatment plan to determine the medical necessity and appropriate level of care for radiation therapy services.

This program offers clinicians the necessary flexibility to render appropriate quality care in a timely manner and it ensures safety by requiring technologies used in radiation therapy to conform to appropriate standards established by a national board of recognized radiation oncologists.

• Services provided include:

  – Radiation therapy utilization management

  – Online tools

For more information, including program criteria, impacted services and FAQs, click here.