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  • Radiation Therapy Program > Prior Approval Procedures

    Services Requiring Prior Approval

    All outpatient radiation therapy services require prior approval. eviCore has specific cancer clinical pathways, indicated below. For cancers less commonly treated with radiation therapy, the prior authorization follows an "Other Cancer Types" clinical pathway.

    • Bone Metastases
    • Brain Metastases
    • Breast Cancer
    • Cervical Cancer
    • Endometrial Cancer
    • Gastric Cancer
    • Head/Neck Cancer
    • Non-Cancerous Indications
    • Non-Small Cell Lung Cancer
    • Other Cancer Types
    • Pancreatic Cancer
    • Primary Central Nervous System Lymphoma
    • Primary Central Nervous System Neoplasms
    • Prostate Cancer
    • Rectal Cancer
    • Small Cell Lung Cancer

    Each particular radiation treatment plan requires prior approval. Prior approvals are specific to the cancer type being treated. They have an expiration date based on the cancer diagnosis, treatment modality and the number of phases and fractions being requested. Prior approval must be obtained for radiation therapy treatment used to treat both malignant and benign indications.

    Prior approval is required for services performed in the following places of service:

    • Ambulatory surgery centers (POS 24)
    • Freestanding radiology facilities (POS 11)
    • Outpatient facilities (POS 22)
    • Practitioner offices (POS 11)

    Claims will be denied for procedures that require but did not receive prior approval or appropriate authorization through eviCore. In such cases, the member will not be held liable for billing or payment.

    Who Requests Prior Approval

    It is the responsibility of the referring practitioner (i.e., the practitioner developing the patient's treatment plan) to obtain the prior approval before services are rendered. If the referring practitioner and rendering practitioner are different, the rendering practitioner is encouraged to confirm that a prior approval is on file before services are rendered.

    How To Request Prior Approval

    Before requesting prior approval from eviCore, please have the medical records on hand and complete the form specific to the type of cancer being treated and the procedure being requested. These forms are available at the links below and at www.evicore.com. evieCore lists all clinical questions the practitioner must answer during the initial prior approval review.

    Once the form is completed, submit prior approval requests in one of two ways:

    • Online: Visit www.evicore.com. To submit online requests, the ordering physician must be a registered user. To register for a user ID and password, visit www.evicore.com and select "Register."
    • By phone: Call 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. Representatives are available Monday through Friday, from 7 am to 7 pm. eviCore is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving, and Christmas Day.

      Expedited Prior Approval Requests

      The eviCore website cannot be used for expedited approval requests. These requests must be processed through the eviCore call center. Call 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. eviCore utilization review staff is available 24 hours a day, 7 days a week. eviCore is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving, and Christmas Day.

      To expedite prior approvals, please have the following information on hand (please see forms at links above or at www.evicore.com:

      • Cancer type being treated with radiation therapy
      • Patient information
      • Ordering practitioner information
      • Rendering site information
      • Patient history
        • Recent test results
        • Work up
        • Current clinical condition
      • Treatment plan specifics, which may include:
        • Immobilization techniques
        • Treatment plan
        • Treatment technique
        • Fields/angles
        • Fractions
        • Boost

        Urgent Requests

        If the radiation treatment is medically urgent and must be performed outside eviCore's business hours, the physician may deliver treatment and must submit the prior approval request (with supporting clinical documentation) within two business days. Urgent requests are reviewed against medical necessity criteria, and an approval is issued as long as the request meets this criteria. Urgent requests will be completed within 24 hours of receiving the request.

        The eviCore website cannot be used for urgent approval requests. These requests must be processed through the eviCore call center. Call 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. eviCore utilization review staff is available 24 hours a day, 7 days a week. eviCore is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving, and Christmas Day.

        Non-Urgent Requests

        Non-urgent requests will be completed within three business days of receiving all necessary information. In most cases, eviCore will review and determine prior approvals during the initial phone call, as long as all the required information is provided. The review and determination processes may take longer if member or practitioner eligibility verification is required or if the request requires additional clinical review.

        A physician with office hours later than eviCore's call center may initiate a case through eviCore's website. eviCore will process the request on the next business day.

        Modifying Prior Approval Requests

        If during a course of treatment the rendering physician opts to modify an approved treatment plan, the referring or rendering physician should call eviCore to discuss the new treatment plan. This allows eviCore to adjust the existing prior approval or create a new prior approval as needed. The referring or rendering physician must submit the supporting clinical history to determine medical necessity. The referring or rendering physician will then be notified as to whether the proposed changes to the treatment plan are deemed medically necessary. If the prior approval for the treatment plan is not updated and the claim does not match the authorized procedures, the claim will be denied for payment, with no liability to the member.

        Prior Approval for Additional Treatment

        The prior approval is valid for the approved treatment plan (an "episode of care"). If the member is provided with an additional episode of care, the referring and rendering physicians must communicate with eviCore about the member's care because a new prior approval will be required.

        Verifying the Prior Approval Status

        The practitioner who renders the services (e.g., the practitioner rendering the service at the outpatient hospital or ambulatory care center) is responsible for ensuring that the appropriate approval is on file. The appropriate staff at the location where services are rendered should verify the status of a prior approval request by calling 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans.

        You can also verify the prior approval request on the Authorization Lookup section of www.evicore.com. eviCore's prior approval determinations do not display at www.emblemhealth.com.

        Please note that while eviCore may approve or deny a prior approval request, this determination is based on medical necessity only. Always verify member eligibility, benefits and copayments directly with EmblemHealth at www.emblemhealth.com.

        Prior Approval Authorized Treatment

        One prior approval is assigned per treatment plan. It includes the time frame for the treatment plan and any approved scans and simulations. Also, one prior approval number is assigned per course of treatment. This number applies to all services/CPT codes that are part of the approved treatment plan.

        The prior approval letter includes the prior approval number, time frame the treatment is valid for, type of technique, number of phases, number of gantry angles, number of fractions, select CPT codes and claim instructions. If you have any questions about what is authorized, please call eviCore at 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans.

        Prior Approval Duration

        The duration, or validity period, of a prior approval is communicated once the treatment plan is approved. If additional time is needed, the referring or rendering physician must contact eviCore to request an extension. The physician may contact eviCore's Clinical Review Department at 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. Claims will be denied for services performed without prior approval.

        Determination Disagreement

        If a referring or rendering physician disagrees with the eviCore determination, contact eviCore's Peer-to-Peer Consultation Line to discuss the case with a eviCore medical director. Call 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans.

        CPT Codes Requiring Prior Approval

        The following CPT codes require prior approval for all plans covered by the EmblemHealth Radiation Therapy Program:

        EmblemHealth Radiation Therapy Code List

        Effective October 1, 2012

        CPT Code Procedure Description CPT Code Procedure Description
        00330* RADIOLOGY/THERAPEUTIC – GENERAL CLASSIFICATION 77417 THERAPEUTIC RADIOLOGY PORT FILMS
        00333* RADIOLOGY/THERAPEUTIC – RADIATION THERAPY 77418 IMRT TREATMENT DELIVERY; SINGLE OR MULTIPLE FIELDS/ ARCS, VIA NARROW SPATIALLY AND TEMPORARILY MODULATED BEAMS, BINARY, DYNAMIC MLC, PER TREATMENT SESSION
        00339*  RADIOLOGY/THERAPEUTIC – OTHER 77421 STEREOSCOPIC X–RAY GUIDANCE FOR LOCALIZATION OF TARGET VOLUME
        00344* THERAPEUTIC RADIOPHARMACEUTICALS 77422 HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA USING A SINGLE PORT OR PARALLEL-OPPOSED PORTS WITH NO BLOCKS OR SIMPLE BLOCKING
        00973*  RADIOLOGY/THERAPEUTIC – PROFESSIONAL FEES
        77423 HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; 1 OR MORE ISOCENTER(S) WITH COPLANAR OR NON-COPLANAR GEOMETRY WITH BLOCKING AND/OR WEDGE, AND/OR COMPENSATOR(S)
        19296*  PLACEMENT OF RADIATION THERAPY AFTERLOADING EXPANDABLE CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, ON DATE SEPARATE FROM PARTIAL MASTECTOMY 77427 RADIATION TREATMENT MANAGEMENT, FIVE TREATMENTS
        19297* PLACEMENT OF RADIATION THERAPY AFTERLOADING EXPANDABLE CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING
        PARTIAL MASTECTOMY, CONCURRENT WITH PARTIAL MASTECTOMY
        77431 RADIATION TREATMENT MANAGEMENT, WITH COMPLETE COURSE OF THERAPY CONSISTING OF 1 –2 FRACTIONS ONLY
        19298  PLACEMENT OF RADIATION THERAPY AFTERLOADING BRACHYTHERAPY CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY
        77432 STEREOTACTIC RADIATION TREATMENT MANAGEMENT CEREBRAL LESION(S) COMPLETE COURSE OF TREATMENT CONSISTING OF 1 SESSION
        32553  PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (E.G., FIDUCIAL MARKERS, DOSIMETER), PERCUTANEOUS, INTRA–THORACIC, SINGLE OR MULTIPLE 77435 STEREOTACTIC BODY RADIATION TREATMENT MANAGEMENT PER TREATMENT COURSE; 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS
        55920 PLACEMENT OF NEEDLES OR CATHETERS INTO PELVIC ORGANS AND/OR GENITALIA (EXCEPT PROSTATE) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION 77523 PROTON TREATMENT DELIVERY, INTERMEDIATE
        57155 INSERTION OF UTERINE TANDEM AND/OR VAGINAL OVOIDS FOR CLINICAL BRACHYTHERAPY 77525 PROTON TREATMENT DELIVERY, COMPLEX
        57156 INSERTION OF A VAGINAL RADIATION AFTERLOADING APPARATUS FOR CLINICAL BRACHYTHERAPY 77600 HYPERTHERMIA, EXTERNALLY GENERATED; SUPERFICIAL (I.E., HEATING TO A DEPTH OF 4 CM
        OR LESS)
        58346 INSERTION OF HEYMAN CAPSULES FOR CLINICAL BRACHYTHERAPY 77605 HYPERTHERMIA, EXTERNALLY GENERATED; DEEP (I.E., HEATING TO DEPTHS GREATER THAN 4 CM)
        76950 ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS 77610 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); 5 OR FEWER INTERSTITIAL APPLICATORS
        76965  ULTRASOUND GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION 77615 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); MORE THAN 5 INTERSTITIAL APPLICATORS
        77011  COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION 77620 HYPERTHERMIA GENERATED BY INTRACAVITARY PROBES
        77014  COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS 77750 INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION (INCLUDES 3-MONTH FOLLOW-UP CARE)
        77261 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE 77761 INTRACAVITARY RADIATION SOURCE APPLICATION; SIMPLE
        77262 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; INTERMEDIATE 77762 INTRACAVITARY RADIATION SOURCE APPLICATION; INTERMEDIATE
        77263  THERAPEUTIC RADIOLOGY TREATMENT PLANNING; COMPLEX 77763  INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX
        77280  THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; SIMPLE 77776 INTERSTITIAL RADIATION SOURCE; SIMPLE
        77285 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; INTERMEDIATE 77777 INTERSTITIAL RADIATION SOURCE; INTERMEDIATE
        77290  THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX 77778 INTERSTITIAL RADIATION SOURCE; COMPLEX
        77295  THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; 3-DIMENSIONAL 77785 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; 1 CHANNEL
        77299  UNLISTED PROCEDURE; THERAPEUTIC RADIOLOGY CLINICAL TREATMENT PLANNING 77786 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; 2–12 CHANNELS
        77300  BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL AXIS DEPTH DOSE CALCULATION, TDF, NSD, GAP CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON-IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN 77787 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; OVER 12 CHANNELS
        77301 INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE-VOLUME HISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS 77789 SURFACE APPLICATION OF RADIATION SOURCE
        77305 TELETHERAPY ISODOSE PLAN; SIMPLE 77790 SUPERVISION, HANDLING, LOADING OF RADIATION SOURCE
        77310 TELETHERAPY ISODOSE PLAN; INTERMEDIATE 77799 UNLISTED PROCEDURE, CLINICAL BRACHYTHERAPY
        77315  TELETHERAPY ISODOSE PLAN; COMPLEX 0073T  OMPENSATOR-BASED BEAM MODULATION TREATMENT DELIVERY OF INVERSE PLANNED TREATMENT USING 3 OR MORE HIGH RESOLUTION (MILLED OR CAST) COMPENSATOR CONVERGENT BEAM MODULATED FIELDS, PER TREATMENT SESSION
        77321 SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMIBODY, TOTAL BODY 0182T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, PER FRACTION
        77326  BRACHYTHERAPY ISODOSE PLAN; SIMPLE  0197T INTRA-FRACTION LOCALIZATION AND TRACKING OF TARGET OR PATIENT MOTION DURING DELIVERY OF RADIATION THERAPY (E.G., 3D POSITIONAL TRACKING, GATING, 3D SURFACE TRACKING), EACH FRACTION OF TREATMENT
        77327 BRACHYTHERAPY ISODOSE PLAN; INTERMEDIATE C1715 BRACHYTHERAPY NEEDLE
        77328  BRACHYTHERAPY ISODOSE PLAN; COMPLEX C1716 BRACHYTHERAPY SOURCE, NON-STRANDED, GOLD-198, PER SOURCE
        77331  SPECIAL RADIATION DOSIMETRY C1717 BRACHYTHERAPY SOURCE, NON-STRANDED, GOLD-198 PER SOURCE
        77332  TREATMENT DEVICES, DESIGN AND CONSTRUCTION; SIMPLE C1719 BRACHYTHERAPY SOURCE, NON-STRANDED, NONHIGH DOSE RATE IRIDIUM-192, PER SOURCE
        77333  TREATMENT DEVICES, DESIGN AND CONSTRUCTION; INTERMEDIATE C1728 CATHETER, BRACHYTHERAPY SEED ADMINISTRATION
        77334  TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX C2634 BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, IODINE-124, GREATER THAN 1.01 MCI
        77336  CONTINUING MEDICAL PHYSICS CONSULTATION C2635 BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, PALLADIUM-103, GREATER THAN 2.2 MCI
        77338  MULTI-LEAF COLLIMATOR (MLC) DEVICE(S) FOR INTENSITY MODULATED RADIATION THERAPY (IMRT), DESIGN AND CONSTRUCTION PER IMRT PLAN C2636 BRACHYTHERAPY LINEAR SOURCE, NON-STRANDED, PALADIUM-103, PER 1MM
        77370  SPECIAL MEDICAL RADIATION PHYSICS CONSULTATION C2637 BRACHYTHERAPY SOURCE, NON-STRANDED, YTTERBIUM-169, PER SOURCE
        77371  RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CEREBRAL LESION(S) CONSISTING OF 1 SESSION, MULTI-SOURCE COBALT 60 BASED  C2638 BRACHYTHERAPY SOURCE, STRANDED, IODINE-125, PER SOURCE
        77372  RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS) COMPLETE COURSE OF TREATMENT OF CEREBRAL LESION(S) 1 CONSISTING OF SESSION, LINEAR ACCELERATOR BASED C2639 BRACHYTHERAPY SOURCE, NON-STRANDED, IODINE-125, PER SOURCE
        77373  STEREOTACTIC BODY RADIATION THERAPY DELIVERY PER FRACTION 1 OR MORE LESIONS; INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS C2640 BRACHYTHERAPY SOURCE, STRANDED, PALLADIUM-103, PER SOURCE
        77399  UNLISTED PROCEDURE, MEDICAL RADIATION PHYSICS, DOSIMETRY AND TREATMENT DEVICES, AND SPECIAL SERVICES C2641 BRACHYTHERAPY SOURCE, NON-STRANDED, PALLADIUM-103, PER SOURCE
        77401  RADIATION TREATMENT DELIVERY; SUPERFICIAL AND/OR ORTHO VOLTAGE C2642 BRACHYTHERAPY SOURCE, STRANDED, CESIUM-131, PER SOURCE
        77402  RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS UP TO 5 MEV C2643 BRACHYTHERAPY SOURCE, NON-STRANDED, CESIUM -131, PER SOURCE
        77403 RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 11-19 MEV C2698 BRACHYTHERAPY SOURCE, STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE
        77404 RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 6-10 MEV C2699 BRACHYTHERAPY SOURCE, NON-STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE
        77406  RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 20 MEV AND GREATER C9725  LACEMENT OF ENDORECTAL INTRACAVITARY APPLICATOR FOR HIGH INTENSITY BRACHYTHERAPY
        77407  RADIATION TREATMENT DELIVERY; TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA USE OF MULTIPLE BLOCKS; UP TO 5 MEV C9726 PLACEMENT AND REMOVAL (IF PERFORMED) OF APPLICATOR INTO BREAST FOR RADIATION THERAPY
        77408  RADIATION TREATMENT DELIVERY; TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA USE OF MULTIPLE BLOCKS; 6-10 MEV C9728  LACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY/ SURGERY GUIDANCE (E.G., FIDUCIAL MARKERS, DOSIMETER), OTHER THAN ABDOMEN, PELVIS, PROSTATE, RETROPERITONEUM, THORAX (ANY APPROACH), SINGLE OR MULTIPLE
        77409  RADIATION TREATMENT DELIVERY; TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA USE OF MULTIPLE BLOCKS; 11-19 MEV G0173 LINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION
        77411  RADIATION TREATMENT DELIVERY; TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA USE OF MULTIPLE BLOCKS; 20 MEV OR
        GREATER
        G0251 LINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT
        77412  RADIATION TREATMENT DELIVERY; THREE OR MORE SEPARATE TREATMENT AREAS; CUSTOM BLOCKING, TANGENTIAL PORTS WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; UP TO 5 MEV G0339  IMAGE-GUIDED ROBOTIC LINEAR ACCELERATORBASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION OR FIRST SESSION OF FRACTIONATED TREATMENT
         77413  RADIATION TREATMENT DELIVERY; THREE OR MORE SEPARATE TREATMENT AREAS; CUSTOM BLOCKING, TANGENTIAL PORTS WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; 6-10 MV COMPLEX G0340 IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOm PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT
        77414 RADIATION TREATMENT DELIVERY; THREE OR MORE SEPARATE TREATMENT AREAS; CUSTOM BLOCKING, TANGENTIAL PORTS WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; 11-19 MV COMPLEX Q3001 BRACHYTHERAPY RADIOELEMENTS
        77416 RADIATION TREATMENT DELIVERY; THREE OR MORE SEPARATE TREATMENT AREAS; CUSTOM BLOCKING, TANGENTIAL PORTS WEDGES, ROTATIONAL BEAM,
        COMPENSATORS, ELECTRON BEAM; 20 MV OR GREATER 
        S8030 SCLERAL APPLICATION OF TANTALUM RING(S) FOR LOCALIZATION OF LESIONS FOR PROTON BEAM THERAPY
         * Covered if billed with an appropriate CPT code.
         

        Formal Dispute Resolution

        Please submit to EmblemHealth:

        Please submit to eviCore:

        • Expedited and standard clinical appeals for Commercial/Child Health Plus members and expedited and standard action appeals for Medicaid members. Appeals may be filed by the member, the member's delegate (including the practitioner acting as the member's delegate) or the practitioner on his or her own behalf. For a full description of member and practitioner rights regarding clinical and action appeals, see the Dispute Resolution chapters for Commercial/CHP and Medicaid, as applicable.

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        Glossary terms found on this page:

        An activity of EmblemHealth or its subcontractor that results in:

        • Denial or limited authorization of a service authorization request, including the type or level of service
        • Reduction, suspension or termination of a previously authorized service
        • Denial, in whole or in part, of payment for a service
        • Failure to provide services in a timely manner
        • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

        Oral or written request for EmblemHealth to review or reconsider an action by EmblemHealth or its subcontractor.

        All types of health services that are provided on an outpatient basis.

        Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

        Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

        Services that have been approved for payment based on a review of EmblemHealth's policies.

        Services that have been approved for payment based on a review of EmblemHealth's policies.

        Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

        An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

        Occurs when a clinical professional reviews information about a patient's health.

        When a member is covered by more than one benefit plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement. Also called Coordination of Benefits.

        Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

        The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

        The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

        An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

        A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

        The date indicated in an insurance contract as the date coverage expires at 12 midnight.

        An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

        An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

        • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
        • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
        • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
        • Maintains medical records for all patients
        • Has a requirement that every patient be under the care of a member of the medical staff
        • Provides 24-hour patient services
        • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

        Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

        A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

        A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

        Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

        • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
        • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
        • It is in accordance with accepted standards of good medical practice in the community.
        • It is furnished in a setting commensurate with the member's medical needs and condition.
        • It cannot be omitted under the standards referenced above.
        • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
        • It is not furnished primarily for the convenience of the member, the member's family or the provider.
        • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

        The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

        Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

        A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

        An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

        The physician or other provider who specifically prescribes the health care service being reviewed.

        A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

        A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

        The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

        Treatment of disease by X-ray, radium, cobalt or high energy particle sources.

        A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.

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