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Provider Manual

High end imaging and radiation services

Last Updated on November 16, 2018

High end imaging

Security Health Plan requires prior notification for all outpatient high-end imaging tests: MRI, CT (excluding SPECT) and PET scans. A complete list of CPT codes requiring notification can be found below. Services performed without authorization may be denied for payment; and you may not seek reimbursement from members.

A prior notification is required for affiliated providers, facilities and ancillary providers for aforementioned high-end imaging procedures prior to performance, with administrative claim denial for non-compliance. The ordering provider maintains final decision authority of which high-end imaging test is performed. If an affiliated provider fails to prior notify, retro-notification will not be accepted.

The ordering provider or designee is responsible for obtaining a notification number prior to scheduling high-end outpatient imaging procedures. Prior notification can be completed on-line via Security Health Plan’s provider portal.

Authorization is required for:

  • MRI
  • MRA
  • CT
  • CTA
  • PET
  • Nuclear Cardiac

Request Authorization

To request an authorization, submit your request online, by phone or fax:

Call eviCore at 1-888-693-3211 and choose option 4 for physicians. Here, providers may request or schedule a live peer-to-peer conversation. Please have the case or authorization number on the denial/fax letter ready.

Resources

View code list for high end imaging prior authorizations
View code list for Radiation Therapy
eviCore Cardiology & Radiology Clinical Guidelines (effective May 22, 2017)
eviCore FAQs

 

Radiation Services requiring prior authorization

Beginning February 1, 2016, prior authorization from eviCore will be required for radiation oncology.

Beginning February 1, 2016, prior authorization from eviCore will be required for radiation oncology. In the coming weeks we will be adding more information here regarding this topic.

What radiation oncology procedures will require prior authorizations?

  • Effective February 1, 2016 all radiation therapy treatment plans for cancerous and non-cancerous indications will require prior authorization through eviCore regardless of treatment technique, but subject to the member’s eligibility and benefits. When a physician contacts eviCore for a radiation therapy prior authorization, he/she will do so for a complete episode of care rather than a specific CPT code. eviCore collects information about the patient’s diagnosis and the physician’s intended treatment plan to render a medical necessity determination. An approved or partially approved authorization will include all appropriate consultation, planning, simulation, dosimetry, treatment management, guidance, medical physics, and treatment delivery codes.

How will I know what clinical information is required to request an authorization?

  • Physician Worksheets are available at https://www.evicore.com/ .   If updates are made, they are updated and published on a quarterly basis (within the first month of every quarter).  Under solutions, select “Radiation Therapy”. Then select “Clinical Guidelines”.  The physician worksheets are available under the header, “+View more Physician Worksheets”.   The questions asked on the worksheet will mirror those questions asked during the review process.

Common Questions

 
What services require prior authorization from eviCore?
Effective December 1, 2014, Security Health Plan will require affiliated providers to complete prior authorization for non-emergent high-end imaging for CT, MRI, PET and Nuclear Cardiac services.  Security Health Plan will deny professional and technical charges for high-end images that are performed without prior authorization.

To whom does this apply?
This applies to all Security Health Plan commercial, Medicare Advantage and BadgerCare members.  Prior authorization from Security Administrative Services (SAS) is required for most, but not all members of self-funded groups. If prior authorization is given by a company other than SAS, the contact information will appear on the back of the member’s ID card.  Prior authorization of high-end imaging does not apply to Medicare Medical Savings Account members and Family Health Center members.

Who is responsible for initiating the prior authorization?
The ordering and rendering provider are expected to work together to ensure the prior authorization is in place. Either provider can initiate the prior authorization. However, the rendering facility will be responsible to ensure the authorization is in place and approved. The claim will be denied if no prior authorization is on file.

How do I contact eviCore to obtain prior authorization for these services?
eviCores’ Authorization Intake Team, including same-specialty review physicians, is available by calling 888-693-3211 Monday-Friday, 7 a.m. to 8 p.m. CST or by fax at 888-693-3210. Online authorization requests can be made 24 hours a day, 7 days a week using www.medsolutionsonline.com.

Is prior authorization required for emergency department situations?
No. Patients seen in the emergency department or urgent care are exempt from prior authorization. It is not necessary for anyone to call
eviCore retrospectively to authorize any imaging procedure performed during an emergency room or urgent care visit.

How are observation stays handled?
Imaging services that occur during observation stays do not require prior authorization, nor do these services require the physician to contact
eviCore within the next business day of rendering the service, as long as the stay is billed as an observation stay.

What information is required at the time of request?

• Name of office and phone number of ordering physician
• Member name and ID number
• Requested service
• Name of provider office or facility where service is to be performed
• Clinical information supporting request
• Patient symptoms
• Exam findings
• Previous and/or current treatments, previous studies, preliminary services already completed
• Reason study is requested (e.g. further evaluation, rule out disorder)

Can eviCore handle multiple authorization requests per phone call? What is the limit?
There is no limit to the amount of requests submitted per phone call, fax or via the web.

How long is an authorization number valid?
Prior to December 16, 2014, any cases started or in process will be effective for 30 days from the date that service is approved. Beginning Dec. 16, 2014, any newly created prospective authorizations are effective for 60 days from the date the service is approved. Effective July 1, 2016 any newly created prospective authorizations are effective for 90 days from the date of service is approved.

What if my office staff forgets to call eviCore and proceeds with scheduling an imaging procedure or procedure requiring prior authorization?
It is very important to notify office staff and educate them about this policy. eviCore will only permit retrospective requests when clinical urgency prevented prior authorization. Retrospective requests are accepted up to 3 business days following the date of service. Claims that are not preauthorized may not be paid.

Are retrospective requests handled by eviCore?
Yes. eviCore permits retrospective requests only when clinical urgency prevented prior authorization. For a case to be approved, these criteria apply:
• Requested within the time limit
• Meets clinical criteria for appropriateness
• Must be clinically urgent

Cases not submitted on time, for which clinical urgency is not established or for which clinical and administrative criteria are not satisfied will not be approved.

What happens if a patient is authorized for a Computed Tomography (CT) of the abdomen, and the radiologist or rendering physician feels an additional study of the pelvis is needed?
Providers must notify eviCore within 72 hours of the procedure to request an update to an approved prior authorization. eviCore will evaluate the request against medical necessity.

If eviCore denies prior authorization of a study, does the provider have the option to appeal the decision?
Yes. Multiple levels of appeal are available and will be detailed in the denial letter sent to the ordering physician and member. In the event of an adverse determination, eviCore welcomes an informal post-decision review between the provider and the eviCore Medical Director.

Are there any instances where prior authorization is not required?
Radiology procedures that are performed during an emergency room visit, urgent care visit, observation stay or an inpatient admission DO NOT require prior authorization through eviCore. All inpatient stays require separate review and authorization from Security Health Plan’s Utilization Management Teams.

If two prior authorization numbers are associated with the patient encounter, which one should be printed on the claim?
You do not need to enter the eviCore prior authorization number on the claim form or via the electronic transaction. Notification numbers are used for reference only and are not valid for claim payment. It is highly recommended, however, that imaging providers document and archive imaging prior authorization numbers.

If a rural hospital only has a mobile MRI available to the facility on Tuesday and Thursday, and a patient comes into the ER room Saturday, can the ER physician write an order for an MRI to be performed on Tuesday and have it considered an emergency and bypass prior authorization?
No. If the member’s situation is truly emergent, the ordering physician should have the patient transferred to a hospital with the appropriate level of care.

Can the physician speak directly with a clinical reviewer or physician (peer-to-peer) level reviewer?

You may request a peer-to-peer review from eviCore. Initial intake information determines member eligibility and helps to process the request. All peer-to-peer discussion is strongly encouraged to be physician-to-physician. For Medicare Advantage members, peer-to-peer discussion must be completed prior to final organizational determination.

This easy-to-use feature provides a faster way to schedule a clinical consultation for radiology cases. Please note that we will be expanding this capability to other programs in the near future.

To schedule a clinical consultation, visit the evicore provider login page at https://www.evicore.com/pages/providerlogin.aspx and click on the link located below the provider login to get started. From there, select your health plan and solution, then fill out the form with the required information. Once submitted, you will receive a confirmation email and an agent will contact you prior to the time of your request to schedule your exact appointment time.

Where can I go to review the medical necessity criteria guidelines for the services requiring authorization?
Medical necessity criteria guidelines for eviCore can be reviewed  here.
What is the decision time limit for a routine prior authorization decision?
eviCore will render a decision on a routine prior authorization request within 14 calendar days of the original request.

What is the decision time limit for an urgent prior authorization request?
In the event of a clinically urgent/expedited prior authorization request, eviCore will render a decision within 72 hours of the request.

Will pediatric requests require prior authorization?
No. For pediatric cases (under age 19) prior authorization is not required.

Is an authorization required for an advanced imaging service provided to a Security Health Plan member in the emergency room?
Typically, Security Health Plan requires prior authorization for each procedure performed on a member. There are a few scenarios that do not require prior authorizations from eviCore and for which prior authorization requests for studies are not accepted:
• When performed on inpatients or in an inpatient setting
• When performed during an observation stay
• When performed in an emergency setting
• When performed in an urgent care setting

Will rendering facilities be able to initiate prior authorization requests from eviCore?
Yes. Rendering facilities will be able to initiate prior authorization requests from eviCore.
Are eviCores’ authorizations specific or do they allow grouping such as with contrast, without and with contrast, and without contrast?
eviCore considers the individual needs and clinical indications of the patient. This approach ensures authorization of the most appropriate CPT per requested study within a given CPT contrast family. Providers are not required to contact eviCore to downcode contrast.

Who will handle a request for an appeal?
Security Health Plan members will be referred to Security Health Plan for appeal processing.

Is prior authorization required when Security Health Plan is secondary?
No. Prior authorization is not required when Security Health Plan is secondary. The lone exception is that prior authorization is required for State of Wisconsin group, even if Security Health Plan is secondary.

Does the Security Health Plan claim require an exact facility match?
The provider needs to request the intended Security Health Plan participating facility upon requesting the prior authorization. If the facility is changed, the provider will be required to call eviCore to update the request within three business days.

What information is needed on the claim form?
To process the claim efficiently and accurately, the following information is needed:
  • UB04 claim form – enter the ordering provider’s name and NPI number in field 78 – “other”
  • CMS 1500 claim form – enter the ordering provider’s name in box 17 and the NPI in box 17b

How will denied high-end imaging services be identified?
Radiology claims administratively denied for no prior authorization will be identified using the ANSI denial code CO197.

Are all provider specialties required to submit high-end imaging prior authorizations through eviCore?

Yes, with the exception of the following specialists: dentists, endodontists, orthodontists, periodontists, oral maxillofacial surgeons, and oral surgeons.