As previously communicated, providers are required to obtain precertification through CareCore National, LLC (CareCore) for non-emergent outpatient radiation therapy services for all commercial AmeriHealth Pennsylvania HMO and POS members. In addition, we will transition to the use of CareCore Radiation Therapy Utilization Management Criteria when reviewing requests for radiation therapy services starting May 1, 2015. For members under age 19, services requested will always be automatically approved; however, precertification through CareCore is still required to ensure accurate and timely claims payment.

Effective May 1, 2015, the NaviNet web portal will offer direct access to CareCore's provider portal to streamline the process of obtaining precertification. Providers can select CareCore from the Authorizations transaction and will be automatically redirected to CareCore's provider portal without having to re-enter login credentials. Previous credentials used to access CareCore's provider portal are no longer needed when going through NaviNet.

Additional enhancements to NaviNet, including the ability to review finalized precertifications for radiation therapy services precertified by CareCore, will be announced via NaviNet Plan Central later this month.

Precertification guidelines

The criteria that will be used as the basis for reviewing precertification requests as of May 1, 2015, are available on the Radiation Therapy Tools and Criteria page on CareCore's website.

In addition, Medical Policy #09.00.56: Radiation Therapy Services includes a link to the criteria that CareCore will use to determine medical necessity for radiation therapy services as well as a complete list of procedure codes that require precertification. To view this policy, visit our Medical Policy portal. Select Accept and Go to Medical Policy Online, and then select the Commercial tab from the top of the page. Then type the policy number in the Search field.

Requesting precertification

You can initiate precertification for non-emergent outpatient radiation therapy in one of the following ways:

• NaviNet. Select CareCore from the Authorizations transaction.
• Telephone. Call CareCore directly at 1-866-686-2649.

NaviNet is a registered trademark of NaviNet, Inc.