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Precertification has been delegated to eviCore healthcare (eviCore) for:

• Genetic/genomic tests, certain molecular analyses, and cytogenetic tests
• Radiation therapy

Genetic/genomic tests, certain molecular analyses, and cytogenetic tests

Precertification for certain genetic/genomic tests is required through eviCore for all AmeriHealth members.

Please note that the ordering provider is responsible for submitting precertification requests for the applicable tests. Failure to adhere to the precertification process may result in your AmeriHealth patients receiving a bill for the testing.

For laboratory providers: When a request for genetic/genomic testing is received, laboratories must ensure a precertification is on file before rendering services. If precertification is not on file for the member, it is the laboratory’s responsibility to submit a request to eviCore.

In addition, eviCore manages prepayment review for all genetic/genomic tests, along with certain molecular analyses and cytogenetic tests, for all AmeriHealth members.

Policy and guidelines

For additional information on this utilization management program, please refer to Medical Policy #06.02.52: eviCore Lab Management Program on our Medical Policy Portal.

Radiation therapy

Precertification for nonemergent outpatient radiation therapy services is required through eviCore for all commercial members. Precertification is not required when radiation therapy is rendered in the inpatient hospital setting.

The AmeriHealth Radiation Treatment of Breast Carcinoma guideline indicates 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.

Policies and guidelines

For additional information on this utilization management program, please refer to Medical Policy #09.00.56: Radiation Therapy Services on our Medical Policy Portal.

For more information

Please refer to the Clinical Services – Utilization Management or the Specialty Programs sections of the Provider Manual for Participating Profession Providers for more information on eviCore.

Communications