EmblemHealth Cardiology Imaging Program Adds New Members

Date Issued: 10/1/2012

Beginning October 1, 2012, members in the following plans will be added to the EmblemHealth Cardiology Imaging Program managed by eviCore.

  • EmblemHealth Medicare PPO (underwritten by Group Health Incorporated)
  • GHI HMO (underwritten by GHI HMO Select, Inc.)

The following benefit plans underwritten by HIP Health Plan of New York (HIP) and/or HIP Insurance Company of New York (HIPIC):

  • 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.

Program Exclusions
HIP members assigned to a Montefiore CMO, 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 the EmblemHealth Cardiology Imaging Program. These members may be identified by their member ID card.

For prior approval of cardiology imaging services rendered to members assigned to a Montefiore or Health Care Partners PCP, contact these groups directly. For members of one of the four physician group practices, please submit your prior approval for cardiology imaging services to EmblemHealth.

EviCore Responsibilities
eviCore is responsible for conducting pre-service medical necessity reviews for cardiology imaging services on behalf of EmblemHealth, provided in the following settings:

  • Ambulatory surgery centers (POS 24) (for cardiac catheterization only)
  • Physician offices (POS 11)
  • Free-standing radiology facilities (POS 11)
  • Outpatient facilities (POS 22)

Please note: eviCore will be responsible for conducting expedited and standard clinical appeals for HIP and GHI HMO, except for Medicare plan members.

Prior Approval Requests

Prior approval must be obtained from eviCore for all listed cardiology imaging services performed on or after October 1, 2012. 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 telephone prior approvals, call eviCore at 1-800-835-7064, for GHI HMO and EmblemHealth Medicare PPO, Monday through Friday, from 7 am to 7 pm. For HIP members please call 1-866-417-2345, 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 National or by visiting 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.