New EmblemHealth Radiation Therapy Program and EmblemHealth Cardiology Imaging Program and HIP Radiology Program Apply to More Members
Starting October 1, 2012, we're launching a new Radiation Therapy program and making several changes to our Cardiology Imaging and Radiology utilization management programs, both administered by CareCore National, LLC (CareCore). Details follow:
New EmblemHealth Radiation Therapy Program
Through this program, CareCore will manage the prior approval process for certain disease states and associated CPT-4 codes. Prior approvals will be given for a radiation therapy treatment plan rather than for individual CPT-4 codes. Additionally, CareCore will conduct first-level clinical standard and expedited appeals (except for Medicare plan members). This program will apply to select members in GHI HMO, HIP and EmblemHealth plans. Excluded from this program are HIP members assigned to a Montefiore (CMO) or Health Care Partners (HCP) PCP, members assigned to one of the four physician group practices, and members in certain benefit plans.
For this program, prior approval must be obtained from CareCore for radiation therapy services performed on or after October 1, 2012. Prior approval requests can be submitted and validated through www.carecorenational.com or by calling CareCore at 1-866-417-2345, option 1 for plans underwritten by HIP or at 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans.
Expansion: EmblemHealth Cardiology Imaging Program
Starting October 1, 2012, the EmblemHealth Cardiology Imaging Program will apply to EmblemHealth Medicare PPO and GHI HMO plan members. This program is already in place for EmblemHealth Medicare HMO and other plans underwritten by HIP.
As the program manager, CareCore is responsible for conducting pre-service medical necessity reviews for cardiology imaging services in most outpatient settings. Prior approval is not required for services provided as part of an inpatient hospital stay or an emergency room encounter.
Prior approval requests may be submitted and validated through www.carecorenational.com or by calling CareCore at 1-800-835-7064.
Expansion: HIP Radiology Program
Starting October 1, 2012, the HIP Radiology Program will apply to members in certain additional HIP and EmblemHealth benefit plans underwritten by HIP Health Plan of New York (HIP) or HIP Insurance Company of New York (HIPIC). HIP members assigned to Montefiore CMO or Health Care Partners (HCP) primary care physicians and members assigned to one of the four physician group practices are excluded from this program.
Prior approval must be obtained from CareCore for radiology services performed on or after October 1, 2012. Prior approval requests may be submitted and validated through www.carecorenational.com or by calling CareCore at 1-866-417-2345. The scheduling program now in place for HIP plans under the EmblemHealth Radiology Program will, as of October 1, 2012, apply to the additional plans eligible for this program as of that date.
For GHI HMO providers, the following policy changes take effect November 1, 2012: GHI HMO orthopedists, neurologists and neurosurgeons requesting prior approvals for MRIs and CTs for GHI HMO members will be required to fax clinical notes to CareCore National, LLC, at 1-800-540-2406.
CareCore will provide a Radiation Therapy Program training module on their Web site, www.carecorenational.com. If you have further questions about the Radiation Therapy Program, the EmblemHealth Cardiology Imaging or the HIP Radiology Programs, please contact us by signing into our Message Center on our secure provider Web site.