AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (collectively, AmeriHealth New Jersey) are introducing new precertification requirements for non-emergent outpatient radiation therapy services for all commercial and Medicare Advantage AmeriHealth New Jersey members. AmeriHealth New Jersey will work with CareCore National, LLC d/b/a eviCore healthcare (eviCore), a specialty benefit management company, to manage precertification requests for non-emergent outpatient radiation therapy services.

Services that require precertification

Effective for dates of service on or after January 1, 2016, ordering physicians must contact eviCore to obtain precertification for elective, non-emergent outpatient radiation therapy services. Below is a list of radiation therapy services that will require precertification*:

• external beam, including 2D, 3D conformal, intensity-modulated (IMRT), tomotherapy, image-guided radiation therapy (IGRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS);
• proton beam radiation therapy;
• brachytherapy, including low-dose rate (LDR), high-dose rate (HDR), and outpatient intra-operative techniques (IORT);
• hyperthermia;
• neutron radiotherapy;
• radio-labeled drugs used for radiation therapy (e.g., Radium Ra 223 dichloride [Xofigo^®], ibritumomab tiuxetan [Zevalin^®]).

*This list of services is subject to change. Be sure to verify precertification requirements at the time of service. Please note that for members under the age of 19, services requested will be automatically approved; however, precertification through eviCore is still required to ensure accurate and timely claims payment. As a reminder, precertification requests for all high-technology diagnostic imaging services (e.g., CT, MRI, PET) will continue to be handled through the current process by AIM Specialty Health^®.

Precertification guidelines

The AmeriHealth criteria that will be used as the basis for reviewing precertification requests are available on eviCore's website. In addition, the Notifications for the following medical policies include a link to the criteria that eviCore will use to determine medical necessity for radiation therapy services as well as a complete list of procedure codes that require precertification:

• Commercial: #09.00.56b: Radiation Therapy Services;
• Medicare Advantage: #MA09.020b: Radiation Therapy Services.

To view the Notifications for these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial or Medicare Advantage under Notifications.

Requesting precertification

To initiate precertification for non-emergent outpatient radiation therapy, providers will use the NaviNet^® web portal. Select eviCore/CareCore from the Authorizations option in the Workflows menu, and a new window will open that sends providers directly to eviCore?s provider portal and initiates the precertification process. Once on eviCore's portal, you will be required to create a login and password. This login 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. Starting December 17, 2015, you can request precertification for dates of service on or after January 1, 2016, by calling eviCore directly at 1-866-686-2649 or submitting requests via NaviNet.

For more information

If you have questions about these new precertification requirements, contact your Provider Partnership Associate, call Customer Service at 1-888-YOUR-AH1 ( 1-888-968-7241), or call eviCore at 1-866-686-2649.

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