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As previously communicated, providers are required to obtain
precertification through CareCore National, LLC (CareCore), an independent
company, for non-emergent outpatient radiation therapy services for all
commercial and Medicare Advantage HMO, POS, and PPO 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, the following medical policies include 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:
- Commercial: #09.00.56: Radiation Therapy Services;
- Medicare Advantage: #MA09.020: Radiation Therapy Services.
To view these policies, visit our
Medical Policy Portal. Select
Accept and Go to Medical
Policy Online, and then select the
Commercial or
Medicare
Advantage tab from the top of the page, depending on the version of the
policy you'd like to view. Type the policy name or 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., an independent company.
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