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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. As of May 1, 2015, we transitioned to the use of CareCore Radiation Therapy Utilization Management Criteria when reviewing requests for radiation therapy services. 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.
Direct access through NaviNet®
As of May 1, 2015, the NaviNet web portal offers direct access to CareCore's provider portal to streamline the process of obtaining precertification. Providers can select CareCore from the Authorizations transaction and a new window will open that sends providers directly to CareCore's provider portal and allows initiation of the precertification process.
![CareCore]()
From this page, select the
Request a clinical certification/procedure option. Within the Clinical Certification section, providers can identify themselves by using either NPI or TIN, along with last name, city, and ZIP. The search will return any referring provider associated with the information entered. Simply select the appropriate provider/address to proceed with the remainder of the precertification process.
Additional enhancements to NaviNet, including the ability to review finalized precertifications for radiation therapy services precertified by CareCore, have been postponed and will be announced in July.
Precertification guidelines
The criteria that will be used as the basis for reviewing precertification requests 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: #09.00.56a: Radiation Therapy Services;
- Medicare Advantage: #MA09.020a: 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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