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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. For members under
age 19, services requested will be automatically approved. However,
precertification through CareCore is still required to ensure accurate and
timely claims payment.
Beginning May 1, 2015, Independence will transition to the use of
CareCore Radiation Therapy Criteria related to outpatient radiation therapy
services. In addition, Independence will delegate precertification for proton
beam radiation therapy, radium Ra 223 dichloride (Xofigo®), and
immunotherapy using Zevalin® to CareCore. Note: Proton
beam radiation therapy and radium Ra 223 dichloride (Xofigo®)
currently require precertification by Independence. Providers must continue to
request precertification for these services using the Authorizations
transaction on the NaviNet® web portal until April 30, 2015.
Note: Precertification is not required when radiation therapy is
rendered in the inpatient hospital setting. Also, these precertification
requirements do not apply to Federal Employee Program, Comprehensive Major
Medical, Traditional/Indemnity, or Medigap Security members.
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. Then 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.
- CareCore provider portal. Access the CareCore provider
portal directly. 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.
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.
NaviNet is a registered trademark of NaviNet, Inc., an
independent company.
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