New HIP Members Added to the HIP Radiology Program

Date Issued: 10/1/2012

In addition to the members currently covered by our HIP Radiology Program members in the following benefit plans underwritten by HIP Health Plan of New York (HIP) and/or HIP Insurance Company of New York (HIPIC) will also be included:

  • CompreHealth EPO
  • EPO 1199
  • HIPaccess® I (HMO)
  • HIPaccess® II (POS)
  • HIP Prime® EPO
  • HIP Prime® PPO
  • HIP Select® EPO
  • HIP Select® PPO

This program does not change members' benefits or claim submission procedures for providers who are directly contracted with one of EmblemHealth's companies. Radiologists directly contracted with eviCore are now required to submit claims to eviCore pursuant to a notice sent to the eviCore provider network dated on or about October 3, 2012.

Program Exclusions

HIP members assigned to a Montefiore CMO or Health Care Partners PCP, or members assigned to one of the four physician group practices: Queens-Long Island Medical Group, Staten Island Physician Practice, Manhattan’s Physician Group and Preferred Health Partners are excluded from this program.

For prior approvals of radiology services rendered to members assigned to Montefiore or Health Care Partners, please contact these entities directly. For members of one of the four physician group practices, submit your prior approval for these services to EmblemHealth.

These members may be identified by their member ID card.

eviCore Responsibilities

Under this program, eviCore is responsible for conducting pre-service medical necessity reviews for radiology and cardiology imaging services provided in the following settings:

  • Free-standing radiology facilities (POS 11)
  • Outpatient facilities (POS 22)
  • Physician offices (POS 11)

eviCore will be responsible for conducting expedited and standard clinical appeals for these additional HIP plans.

Prior Approval Requests
Prior approvals must be obtained from eviCore for all listed radiology services performed on or after October 1, 2012, for these newly added HIP benefit plans. Requests for prior approvals for services to be rendered on or after October 1, 2012, have been accepted since September 17, 2012. For online requests go to eviCore’s Web site; for prior approvals by telephone, call eviCore at 1-800-417-2345, Monday through Friday, from 7 am to 7 pm.

Prior approval is not required for services provided as part of an inpatient hospital stay or an emergency room encounter.

When submitting your request, please note that each separate procedure requires a separate prior approval. Each prior approval is CPT-4 and site location specific and is valid for 45 days from the date approved by eviCore. Rendering providers may verify the status of a prior approval request by calling eviCore or by visiting www.evicore.com.

Accessing eviCore’s Web site
If you are not already registered with eviCore, you may register online to obtain a user ID and password on the eviCore Web site. You may also choose Register at the eviCore home page.