New EmblemHealth Radiation Therapy Program Starts October 1 2012

Date Issued: 10/1/2012

The EmblemHealth Radiation Therapy Program begins October 1, 2012. For EmblemHealth members beginning radiation therapy prior to October 1, 2012, and who will continue radiation therapy beyond that date, the patient’s treatment plan must be registered with CareCore. Registration of cases or requests for prior approval of anticipated care rendered on or after October 1, 2012, began on September 17, 2012.

CareCore National, LLC. (CareCore) will be responsible for processing prior approval requests, conducting medical necessity determination reviews for radiation therapy services on behalf of the EmblemHealth Radiation Therapy Program, as well as conducting standard and expedited clinical appeals (except for Medicare members).

Affected Diagnoses and Treatment Goals
You may view the criteria for our Radiation Therapy Program. All clinical criteria used in CareCore’s medical necessity determinations are consistent with EmblemHealth Medical Policy.

The following list of diagnoses requires a medical necessity determination and prior approval for services rendered as part of the EmblemHealth Radiation Therapy:

  • Bone metastases
  • Brain metastases
  • Breast cancer
  • Cervical cancer
  • Endometrial cancer
  • Gastric cancer
  • Head/neck carcinoma
  • Non-small cell lung cancer
  • Pancreatic cancer
  • Primary CNS lymphoma
  • Primary CNS neoplasm
  • Prostate adenocarcinoma
  • Rectal adenocarcinoma
  • Small-cell lung cancer
  • Other cancer
  • Non-cancerous indications 
  • (Note: prior approvals will be given for a radiation therapy treatment plan rather than for individual CPT-4 codes.)

    Plans Included in Our Radiation Therapy Program

    Plans underwritten by HIP:

    • HIP commercial plans (HMO, POS, EPO or PPO) — except Vytra HMO and FEHB plans
    • HIP state-sponsored programs (Medicaid, Family Health Plus and Child Health Plus)
    • EmblemHealth CompreHealth EPO and HMO plans
    • EmblemHealth Medicare HMO plans — except Medicare Cost

    Plans underwritten by GHI and GHI HMO Select, Inc. plans:

    • GHI HMO plans
    • EmblemHealth Medicare PPO plans

    Program Exclusions

    Contact Montefiore CMO or Health Care Partners for prior approval of radiation therapy services for HIP members assigned to these organizations.

    For prior approval of these program services contact EmblemHealth for HIP 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.

    Members in these benefit plans may be identified by their member ID cards

    Prior Approvals
    Requests and registrations may be submitted to CareCore’s Web site or by calling CareCore at 1-866-417-2345 for plans underwritten by HIP, and at 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO, from Monday through Friday, 7 am to 7 pm.

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

    • Physician offices and free-standing radiology facilities (11)
    • Outpatient facilities (22)
    • Ambulatory surgery center (24)

    If a patient requires radiation therapy treatment for multiple service sites at the same time, separate approval requests are required and may be submitted at the same time.

    Please note: Patient treatment plans for radiation therapy beginning before October 1, 2012, and continuing beyond that date must be registered with CareCore. The treatment plans must be registered with CareCore to ensure accurate claims payment. This will not affect a patient’s existing treatment plan. If a member is in the middle of a course of treatment on October 1, 2012, then CareCore will not conduct a full medical necessity review.

    Accessing CareCore’s Web site
    Providers who already have a user ID and password for CareCore’s site for EmblemHealth’s Radiology or Cardiology Imaging Programs do not need to register again. Providers not already registered may obtain a user ID and password from CareCore by registering online.

    How to Submit a Request for Prior Approval

    A specialist (e.g. Radiation Oncologist) who is requesting the prior approval for the treatment plan and/or is coordinating the member’s treatment is responsible for requesting prior approval. The request may be submitted up to two (2) weeks in advance of service.

    The preferred method for submitting prior approval requests is through the CareCore Web site. No mail or fax requests will be accepted for the Radiation Therapy program; however, telephonic requests will be accepted from providers who do not have access to the Web site. CareCore may be contacted as follows:

    • For HIP Members: 1-866-417-2345, Monday through Friday, from 7 am to 7 pm.
    • For GHI HMO & EmblemHealth Medicare PPO members: 1-800-835-7064, Monday through Friday, from 7 am to 7 pm.

    Urgent Requests for Prior Approval

    If the treatment is medically urgent and must be performed outside of CareCore’s business hours, the physician may deliver treatment and submit the approval request (with supporting clinical documentation) within two (2) business days.

    Urgent requests must be submitted directly through the CareCore call center by calling one of the numbers listed above. These requests will be approved based on medical necessity criteria and completed within 24 hours of receiving the request.

    Available Training

    CareCore has provided an online training module to help you learn more about the Radiation Therapy Program. You may also find additional information about CareCore, their policies, procedures and plan-specific information you and your staff will need to participate in the program on CareCore’s Web site.

    Modifying a Treatment Plan If the treatment plan requires modification during the course of treatment, you must contact CareCore National by telephone; adjustments cannot be processed through the web.

    Approvals cover a specific time period. If the approved treatment is not completed by the assigned Last Covered Day, you must contact CareCore for an extension.

    Peer to Peer Discussions

    Peer-to-peer discussions are available during normal business hours. Call 1-866-417-2345, for cases involving HIP and 1-800-835-7064 for cases involving GHI HMO and EmblemHealth Medicare PPO plan members.

    Clinical Appeals

    If you do not agree with the medical necessity determination for your radiation therapy prior approval request, you may contact CareCore to speak with a Medical Director and discuss your case in detail.

    To appeal a clinical decision for radiation therapy in writing:

    • Mail to: CareCore National, LLC
      Attention: Clinical Appeals Department
      400 Buckwalter Place Boulevard
      Bluffton, SC 29910
    • Fax to: 1-866-699-8128
    • Email to: