As of January 1, 2015, precertification is required for
non-emergent outpatient radiation therapy services for all commercial and
Medicare Advantage HMO and PPO members. Independence is working with CareCore
National, LLC (CareCore), an independent company, to manage precertification
requests for non-emergent outpatient radiation therapy services.
Precertification is not required when radiation therapy is rendered in the
inpatient hospital setting. Furthermore, although precertification isn?t
required for members ages 19 and under, we will require notification to
CareCore for these members to ensure timely and accurate claims payment.
You can initiate precertification for non-emergent outpatient radiation
therapy in one of the following ways:
- NaviNet® web portal. A new option was added
within the Authorizations transaction that links to the CareCore provider
portal.
- CareCore provider portal. Access the CareCore provider
portal directly at www.carecorenational.com. A
login and password are required. This login information will be needed every
time you request precertification through CareCore. If you already have access
to the CareCore provider portal, please use your current login
information.
- Telephone. Call CareCore directly at
1-866-686-2649.
Services that require precertification
The following radiation therapy procedures require precertification through
CareCore as of January 1, 2015:
- external beam, including 2D, 3D conformal, intensity-modulated radiation
therapy (IMRT), tomotherapy, image guided radiation therapy (IGRT),
stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery
(SRS);
- 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, with the exception of Ra
223 (Xofigo®) and immunotherapy using Zevalin®
.
Starting in April 2015, precertification requests for
non-emergent outpatient radiation therapy will be reviewed for medical
necessity. In addition, proton beam radiation therapy, Ra 223
(Xofigo®), and immunotherapy using Zevalin® will
require precertification through CareCore. Note: Proton beam radiation therapy
and Ra 223 (Xofigo®) currently require precertification by
Independence. Providers must continue to request precertification for these
services using the Authorizations transaction on NaviNet until March
31, 2015.
For more information
For more information about radiation therapy services, refer to 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:
- Commercial: #09.00.56: Radiation Therapy Services;
- Medicare Advantage: #MA09.020: Radiation Therapy
Services.
Type the policy name or number in the Search field. You can also view policy
activity through NaviNet by selecting the Reference Tools transaction,
then Medical Policy.
Note: This precertification requirement does not apply to Federal
Employee Program or Comprehensive Major Medical members.
Precertification for high-technology diagnostic imaging
services
Precertification requests for all high-technology diagnostic imaging
services (e.g., CT, MRI, PET) will continue to be handled by AIM Specialty
Health® (AIM), an independent company, through the current
process.
AIM is an independent company contracted with
Independence to perform precertification for select services for most managed
care members.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.