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Provider Manual

High end imaging and radiation services

Last Updated on July 24, 2019

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 FAQs

eviCore healthcare’s Clinical Guidelines and request forms are available at: www.evicore.com or click here to access guidelines specific to Security Health Plan. Please call the Client Provider Operations department at 1-800-646-0418, option 4, if you have any questions or need more information.

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.