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  • Durable Medical Equipment > Members Managed by eviCore

    Starting January 1, 2018, eviCore will manage members who access the following networks:

    • Commercial and Child Health Plus
      • Prime Network
      • Select Care Network
    • Medicaid/HARP
      • Enhanced Care Prime Network
    • Medicare and Special Needs Plans
      • VIP Prime Network

    Exceptions to These Rules

    • Health care professionals treating members whose care is managed by HealthCare Partners and Montefiore were required to contact those managing entities to verify coverage and procedures.

    How to Find a Network DME Provider


    To find a DME provider, go to emblemhealth.com/findadoctor.


    What Requires Prior Approval

    Please refer the Appendix section for the list of Healthcare Procedural Codes (HCPCS) that require prior approval through eviCore.

    Hearing aids - Traditional hearing aids are not part of this program. However, there will be a prior approval process for certain hearing aids including Auditory Osseointegrated Devices.

    Who Needs to Request Prior Approval

    Required Information

    Before requesting prior approval from eviCore, the requesting provider should submit:

    • Patient’s medical records
    • Appropriate request form
    • Details such as: admitting diagnosis, history and physical, progress notes, medication list and wound or incision/location

    The request forms are available at: evicore.com/healthplan/emblem.

    Please send eviCore the supporting clinical documents and the prior approval forms.

    How to Obtain Prior Approval
    Managing Entity Methods to Submit Prior Approval Requests
    eviCore eviCore offers three convenient methods to request prior approval, depending on the Program:

    1. Web Portal submissions are the most efficient way to request prior approvals. Please visit evicore.com/pages/providerlogin.aspx.

    2. Telephone: Clinical information can be called in to eviCore healthcare at 866-417-2345, choose option 3 for HIP members; then option 4 DME and prompt 1 for CPAP and BIPAP or 2 for other DME services.

    3. Facsimile: DME required documentation can be faxed to 866-663-7740.

    For DME requests prior to January 1, 2018, fax to 1-866-426-1509. On or after, December 28, 2017,submit requests to eviCore for anticipated dates of service on or after January 1, 2018.

    DME Suppliers may obtain prior approval details via the eviCore web portal at: evicore.com/pages/providerlogin.aspx or by calling eviCore at: 866-417-2345, option 3 for HIP, then option 4.
    HealthCare Partners Call (800) 877-7587 or fax your request to (888) 746-6433.
    Montefiore CMO Call (888) 666-8326.

    DME Prior Approval Overview

    Notifications to members and providers will be both written and verbal.

    Notification to COMMERCIAL AND MEDICAID MEMBERS:

    Written notification in the form of a letter will be:

    • Faxed to both the referring Physician and DME Supplier
    • Mailed to the member via standard US Mail
    • Available for review on the portal

    Verbal notification:

    • Verbal outreach to members will occur for all determinations

    Notification to MEDICARE MEMBERS

    Written notification in the form of a letter will be:

    • Faxed to both the referring Physician and DME Supplier
    • Mailed to the member via standard US Mail
    • Available for review on the portal

    After the Unable to Approve process has been completed, written notification in the form of a denial letter will be:

    • Faxed to both the referring Physician and DME Supplier
    • Mailed to the member via standard US Mail
    • Available for review on the portal.

    Determination will be made within 2 business days for a routine request and within 3 hours for an Urgent Request.

    Evidence based/Proprietary guidelines for DME Medical Necessity Criteria

    Medicare:
    Medicare Benefit Policy Manual
    National and Local Coverage Determination
    McKesson InterQual® Criteria
    eviCore Clinical Guidelines for PAP devices and supplies

    Medicaid:
    New York State Medicaid Program Criteria
    Durable Medical Equipment, Orthotics, Prosthetics, and Supplies Procedure Code and Coverage Guidelines
    eviCore Clinical Guidelines for PAP devices and supplies
    McKesson InterQual® Criteria

    Commercial:
    McKesson InterQual® Criteria
    eviCore Clinical Guidelines for PAP devices and supplies

    Retrospective Reviews:
    eviCore will accept requests for retrospective reviews of medical necessity for Post-Acute Care. Requests must be submitted within 14 calendar days from the date the initial service was rendered.

    eviCore Healthcare Sleep Program/CPAP Compliance - Program Therapy Support:

    • Beginning January 1, 2018, PAP compliance data will be monitored for Emblem/HIP Commercial, Medicare and Medicaid members by eviCore healthcare. Please visit https: evicore.com/healthplan/emblem for additional program information and reference guides.

    eviCore healthcare DME Reconsideration and Appeals Process:
    Cases that do not meet Medical Necessity may be Reconsidered or Appealed.

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    Glossary terms found on this page:

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

    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.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    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 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 group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    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.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.

    A review done after services are completed (usually as part of a claim or appeal) that ensures the care given was medically necessary.

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