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AmeriHealth has introduced a new utilization management program for
genetic/genomic tests, certain molecular analyses, and cytogenetic tests for
all commercial AmeriHealth members. AmeriHealth will work with CareCore
National, LLC d/b/a eviCore healthcare (eviCore) to manage precertification
and/or prepayment reviews.
This utilization management program will encompass precertification and/or
prepayment review as follows:
- Precertification will be required for certain genetic/genomic tests.
- All genetic/genomic tests, along with certain molecular analyses and
cytogenetic tests, will be reviewed prior to claim payment.
Precertification requirements
Effective for dates of service on or after July 1, 2016, ordering
health care providers and/or laboratories must contact eviCore to obtain
precertification for certain genetic/genomic tests, that include, but are not
limited to, the following:*
- BRCA gene testing
- genetic panels and cancer gene expression tests
- genome-wide tests
- pharmacogenomic tests
These changes will be reflected in an updated precertification requirement
list, which will be posted later this month on the
AmeriHealth New Jersey website and on the
AmeriHealth
Pennsylvania website.
Submitting requests to eviCore
Starting June 27, 2016, you can request precertification for genetic/genomic
tests for dates of service on or after July 1, 2016, by calling eviCore
directly at 1-866-686-2649 or submitting requests via the
NaviNet® web portal.
To submit a request on NaviNet, select CareCore from the
Authorizations option in the Workflows menu, and a new window will open that
sends providers directly to eviCore's provider portal to initiate the
precertification process. Once on eviCore's portal, you will be required to
create a login and password, which will be used every time you request
precertification through eviCore. If you have already established credentials
for eviCore's portal, please use your current login information.
Prepayment review
Starting July 1, 2016, all genetic/genomic tests, along with certain
molecular analyses and cytogenetic tests, will be reviewed by eviCore prior to
claim payment. Examples of molecular analyses and cytogenetic tests include,
but are not limited to, the following:*
- comparative genomic hybridization (CGH)
- fluorescent in situ hybridization (FISH)
- immunohistochemistry (IHC)
- morphometric analyses
Lab management policy and guidelines
A medical policy has been created to provide information about this
utilization management program: #06.02.52: eviCore Lab Management Program,
which will be posted as a Notification on May 2, 2016, and will become
effective July 1, 2016. The policy will include a link to eviCore's Lab
Management Program Clinical Guidelines, which will be used during the
precertification and prepayment review processes, as well as a listing of
procedure codes that will require precertification and/or prepayment
review.
To view the Notification for this policy, visit our Medical Policy
Portal. Select Accept and Go to Medical Policy Online, and then
select Commercial under Notifications.
More information
If you have questions about any of these requirements, you can contact your
Provider Partnership Associate or Network Coordinator or call Customer Service
at 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey or
at 1-800-275-2583 for AmeriHealth Pennsylvania.
*This list of services is subject to change.
Tutorial webinars by eviCore
To assist you in using their provider portal, eviCore will host the
following tutorial webinars called "AmeriHealth Laboratory Management Program
Provider Orientation Session":
- June 21, 2016, 12 ? 1 p.m.
- June 23, 2016, 1 ? 2 p.m.
If you are interested in participating, visit
eviCore?s WebEx page,
select the
Training Center tab, and then choose your preferred session
from the
Upcoming tab. If you have any questions about signing up for
these training sessions, please send an
email.
NaviNet is a registered trademark of NaviNet, Inc.
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