Frequently Asked Questions: EmblemHealth Oncology Drug Management

New Century Health (NCH) is a comprehensive quality management company that EmblemHealth has designated as its newest utilization review agent. NCH offers collaboration and peer-to-peer discussions with oncologists’ and physicians’ offices. They have a provider web portal where you can request preauthorizations, select treatment care pathways, obtain help with documentation, and more.

As of Jan. 1, 2021, NCH handles utilization management for most oncology-related chemotherapeutic drugs and supportive agents when delivered in the physician’s office, outpatient hospital, or other ambulatory setting. NCH emphasizes and supports the selection of Preferred Pathways for adult oncology patient care.

Medical specialties providing cancer care and its supportive services, including medical oncology, hematology, urology, and gynecologic oncology.

Yes, NCH will not manage EmblemHealth Plan, Inc. (formerly GHI) members, members managed by HealthCare Partners and Montefiore CMO, or any members under 18 years of age.

Yes, SOMOS members 18 and over require preauthorization by NCH.

Yes, preauthorization is needed and the request for preauthorization for these members should be sent to Express Scripts:

Express Scripts Pharmacy Drug Reviews for:

·      Commercial members: call 844-516-3324, 24/7/365

·      Medicare members: call 877-920-1470, 24/7/365

  • Medicaid members: call 888-281-5539, 24/7/365

You can also fax requests to 877-251-5896

 

Express Scripts Medical Drug Reviews for:

  • Commercial, Medicare, and Medicaid members: call 877-681-9866, 8 a.m. to 7 p.m., Monday through Friday or fax to 866-896-1209

All chemotherapeutic drugs, symptom management drugs, and supporting agents for members with a diagnosis code included in the following range: C00-D49, E34.0, K31.7, K63.5, L53.8, Q85, D50-D53, D55-D62, D63.0, D63.8, D64, D68.5, D68.6, D69-D77, D89.2, I88, R11 (when cancer related), and Z41.8.

The following services are excluded from the program:

  • Requests for patients under 18 years of age
  • Equipment requests (e.g., IV pump)
  • Inpatient requests
  • Hemophilia drugs
  • Bone marrow transplants
  • Inpatient chemotherapy services
  • ESRD patients
  • Clinical trials
  • Radiopharmaceuticals
  • All places of treatment and services not specifically listed above

Request training on the provider portal. You may also contact NCH Network Operations at 888‑999‑7713, option 6, 8 a.m. to 8 p.m., Monday to Friday.

Preauthorization

NCH’s provider portal is always available, offering:

·       Real-time authorizations for oncology treatment care pathways.

·       Reduced documentation requirements.

·       View of real-time status of preauthorization requests.

·       Eligibility verification.

·       Supportive telephonic authorization staff available at 888-999-7713, 8 a.m. to 8 p.m., Monday to Friday.

·       Quick turnaround time on preauthorization requests submitted via portal, fax, or phone.

·       Peer-to-peer consultations by medical oncologists.

·       An NCH provider representative is available for support as needed.

·       You can also fax preauthorization request forms to 877-624-8602.

All preauthorizations issued by EmblemHealth before Jan. 1, 2021 will remain valid until they expire.

The physician organization ordering chemotherapeutic drugs or supporting agents for the treatment of cancer or related hematologic diseases.

Submit chemotherapy requests to NCH via the following:

  • Sign in to NCH’s provider portal at my.newcenturyhealth.com.
  • Contact NCH’s Utilization Management Intake Department at 888-999-7713, option 6. Hours are 8 a.m. to 8 p.m., Monday to Friday.
  • Fax the preauthorization form that’s in the provider portal to 877-624-8602.

If the request does not meet evidence-based treatment guidelines, NCH may request additional information or initiate a peer-to-peer conversation with the requesting provider. NCH medical reviewers are licensed medical oncologists and use nationally recognized clinical guidelines when performing reviews.

These guidelines are available at my.newcenturyhealth.com or by contacting NCH’s Utilization Management at 888-999-7713, option 6, 8 a.m. to 8 p.m., Monday to Friday.

The preauthorization review process applies to services rendered (e.g., chemotherapy administration) in an outpatient setting, which could include the physician’s office, infusion centers, outpatient hospital locations, and other ambulatory care settings.

Inpatient authorization for chemotherapy should be submitted to Express Scripts:

 

Express Scripts Pharmacy Drug Reviews for:

·      Commercial members: call 844-516-3324, 24/7/365

·      Medicare members: call 877-920-1470, 24/7/365

·      Medicaid members: call 888-281-5539, 24/7/365

 

You can also fax requests to 877-251-5896

 

Express Scripts Medical Drug Reviews for:

Commercial, Medicare, and Medicaid members: call 877-681-9866, 8 a.m. to 7 p.m., Monday through Friday or fax to 866-896-1209

Claims

No. A preauthorization does not guarantee payment for services. Payment of claims is dependent on eligibility, covered benefits, provider contracts, and correct coding and billing practices. For specific details, please refer to your provider manual.

EmblemHealth is responsible for grievance and appeals. Providers can initiate a grievance or appeal with EmblemHealth by mail or fax:

 

Line of Business

Fax #

Mailing Address

Medicare

Standard – 866-854-2763

Expedited – 866-350-2168

 

 

PO Box 2844

New York, NY 10116

Medicaid

 

Standard – 212-510-5320

Expedited – 866-350-2168

Commercial

 

 

For more information on grievance and appeals processes for the above plans, see the following chapters in the EmblemHealth Provider Manual:

 

Dispute Resolution for Commercial and CHP Plans

Dispute Resolution for Medicaid Managed Care Plans

Dispute Resolution for Medicare Plans

 

If authorization is not obtained for the applicable drugs, EmblemHealth may deny payment for respective drugs. Members cannot be held responsible for denied charges/services.

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