AmeriHealth delegates precertification of non-emergent outpatient radiation
therapy services for all commercial HMO, POS, EPO, and PPO members in New
Jersey and commercial HMO and POS members in AmeriHealth Pennsylvania to
CareCore National, LLC d/b/a eviCore healthcare (eviCore). eviCore maintains
Radiation Therapy Clinical Guidelines for AmeriHealth that contain medical
necessity criteria used during the precertification process for our
members.
Effective September 1, 2017, AmeriHealth will update its
Radiation Treatment of Breast Carcinoma guideline to indicate that a
hypofractionated regimen is the preferred treatment for patients with early
stage (T1-2N0) breast carcinoma who meet certain criteria. For these patients,
a request for precertification of conventional fractionation will require a
peer-to-peer call with an eviCore Radiation Oncologist.
The AmeriHealth Radiation Therapy Clinical Guidelines ?
Effective 9/1/2017 is available for review on eviCore?s website.
These guidelines include the updated criteria for treatment of breast carcinoma
using hypofractionated radiation therapy.
Requesting precertification
You can initiate precertification for non-emergent outpatient radiation
therapy services, including radiation treatment of breast carcinoma, in one of
the following ways:
- NaviNet® web portal. Select CareCore
from the Authorizations option in the AmeriHealth Workflows menu.
- Telephone. Call eviCore directly at
1-866-686-2649.
If you have questions about the new guidelines, you may contact eviCore?s
Customer Service support at 1-800-918-8924 from 7 a.m. to 7
p.m.
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