Quick Guide to EmblemHealth’s Radiation Therapy, Cardiology Imaging and Radiology Programs
eviCore healthcare (EviCore) administers several of EmblemHealth’s utilization management programs, which include the EmblemHealth Radiation Therapy program, the EmblemHealth Cardiology Imaging program and the EmblemHealth Radiology Program. The sections below summarize the programs administered by EviCore. Additional information is available in the EmblemHealth Provider Manual.
EmblemHealth Radiation Therapy Program
Through this program, EviCore manages the prior approval process for certain disease states and associated CPT-4 codes. Prior approvals are given for a radiation therapy treatment plan rather than for individual CPT-4 codes. Please refer to the Radiation Therapy Program chapter in the EmblemHealth Provider Manual.
EmblemHealth Cardiology Imaging Program
Through this program, EviCore is responsible for conducting pre-service medical necessity reviews for cardiology imaging services in most outpatient settings. Please refer to the Cardiology Imaging Program chapter in the EmblemHealth Provider Manual.
EmblemHealth Radiology Program
Through this program, EviCore provides diagnostic imaging management for outpatient radiology services. Specific services for which EviCore performs utilization management depend on the EmblemHealth benefit plan. Please refer to the Radiology Program chapter in the EmblemHealth Provider Manual.
Exceptions: When EviCore Programs Do Not Apply
Members whose care is managed by Montefiore Medical Group (CMO) or HealthCare Partners (HCP) must contact the applicable organization for prior approvals. See the member's ID card or eligibility information at emblemhealth.com/Providers to determine whether HIP, CMO, HCP is the Managing Entity responsible for managing a member's care.
HMO or POS members who selected a PCP assigned to AdvantageCare Physicians or St. Barnabas Hospital, as well as Vytra benefit plans are excluded from this program. (See member's ID card.) The referring provider must enter a prior approval request on emblemhealth.com/Providers or vytra.com for Vytra members.
Additional plan exclusions may apply, please refer to the EmblemHealth Provider Manual for the most up-to-date information.
How to Obtain Prior Approval from EviCore
If HIP is the member’s Managing Entity, then EviCore is the organization to contact for prior approval. Before requesting prior approval from EviCore, please have the patient's medical records on hand and complete the form specific to the procedure being requested. These request forms are available at carecorenational.com. The forms list all clinical questions the practitioner must answer during the initial prior approval review. In addition, EviCore conducts first-level clinical standard and expedited appeals (except for Medicare plan members).
Prior approval is not required for services provided as part of an inpatient hospital stay or an emergency room encounter.
For More Information
EviCore provides a Radiation Therapy Program training module on their website: carecorenational.com. If you have further questions about the Radiation Therapy Program, the EmblemHealth Cardiology Imaging or Radiology Programs, please contact us by signing into our Message Center on our secure provider website.
We strongly recommend that providers subscribe to receive updates to the Radiation Therapy Program, Cardiology Imaging Program and Radiology Program chapters of the EmblemHealth Provider Manual. Go to the pertinent chapter and select the subscribe icon. You will be asked to enter your email address.