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Prior Authorization of Advanced Imaging and Cardiology
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Company Overview, eviCore healthcare All Rights Reserved 2. This presentation contains CONFIDENTIAL and PROPRIETARY information. Cardiology, Musculoskeletal, Comprehensive, Solutions Sleep Management. Medical Oncology, Specialty Drug, End to End Solution on a single Radiation Therapy. integrated platform, Lab Management, Post Acute Care. eviCore healthcare All Rights Reserved eviCore healthcare All Rights Reserved 3. This presentation contains CONFIDENTIAL andThisPROPRIETARY information. presentation contains CONFIDENTIAL and PROPRIETARY information. Our Clinical Approach, Clinical Platform, Multi Specialty Expertise.
260 board certified medical, Family Medicine Oncology Hematology. Internal Medicine Surgery, Diverse representation of medical. Pediatrics General, Orthopedic specialties, Sports Medicine Thoracic. Cardiac 450 nurses with diverse, Neurological specialties and experience. Cardiology Otolaryngology, Dedicated nursing and physician.
Nuclear Medicine, teams by specialty for, Anesthesiology Radiology. Cardiology Oncology OB GYN, Radiation Oncology Nuclear Medicine. Spine Orthopedics Neurology, Musculoskeletal, Sleep Medicine Neuroradiology and Medical Surgical. Evidence Based Guidelines, The foundation of our solutions. Contributions Experts Current, Dedicated associated.
pediatric from a panel clinical, with academic, guidelines of community literature. institutions, physicians, Aligned with National Societies. American College of Cardiology American College of Therapeutic Radiology and. American Heart Association, American Society for Radiation Oncology. American Society of Nuclear Cardiology, American Society of Clinical Oncology. Heart Rhythm Society, American Academy of Pediatrics.
American College of Radiology, American Society of Colon and Rectal Surgeons. American Academy of Neurology, American Academy of Orthopedic Surgeons. American College of Chest Physicians, North American Spine Society. American College of Rheumatology, American Association of Neurological Surgeons. American Academy of Sleep Medicine, American College of Obstetricians and.
American Urological Association, Gynecologists, National Comprehensive Cancer Network 6. The Society of Maternal Fetal Medicine, Advanced Imaging and Cardiology. Services Prior Authorization Program, for Highmark. Program Overview, eviCore will begin accepting requests on Dec 17 2018 for dates of service Jan 1 2019 and. Prior authorization applies Prior authorization, to services that are does not apply to services.
that are performed in, Outpatient, Elective Non emergent Emergency room. Diagnostic Inpatient, Observation, It is the responsibility of the ordering provider to request prior. authorization approval for services, It is the responsibility of the rendering provider to verify that the. necessary authorization has been obtained before providing the service 8. Applicable Membership, Authorization by eviCore is required for Highmark members in Pennsylvania. Delaware and West Virginia enrolled in the following programs. Commercial Fully Insured, Commercial Self Insured, Medicare Advantage PA and WV.
Affordable Care Act, Administrative Services Only select groups. Children s Health Insurance Program CHIP PA only, Out of Area select ASO groups. Members who do not require prior authorization are. All other Out Of Area OOA, Benefits can vary by member contract so please be sure to check the. member s benefits before delivering care to confirm if an authorization is. required NaviNet is available to help you check member benefits and to verify. if an authorization is required 9, Advanced Imaging Cardiology Services. Covered Services, Advanced Imaging, PET PET CT, To find a list of CPT.
Nuclear Medicine Current Procedural Terminology, codes that require prior authorization. Cardiology Services through eviCore please visit, Stress Testing. Myocardial Perfusion Imaging SPECT PET https www evicore com healthplan highmark. Stress Echocardiography, Cardiac CT MRI, Echocardiography Transthoracic Transesophageal. Diagnostic Heart Catheterization, Additional Advanced Imaging Cardiology Services. modalities in eviCore s program scope, Prior Authorization Requests.
How to request prior authorization, Available 24 7 and the quickest. way to create prior authorizations, Or by phone, and check existing case status 888 564 5492. 7 00 a m to 7 00, WEB Monday Friday, Fax option 800 540 2406 Fax forms available at www evicore com. Clinical Review Process, Methods of Intake, Predictive. Intelligence Clinical, START Decision Support Real Time Decision with Web.
Appropriate, Easy for providers MD, and staff Review. Consultations, Needed Information, Member Rendering Facility. Member ID Facility name, Member name National provider identifier NPI. Date of birth DOB Tax identification number TIN, Street address. Referring Ordering Physician Requests, Physician name.
National provider identifier NPI, Tax identification number TIN. i CPT code s for, requested imaging, Fax number The appropriate. diagnosis code for the, working of differential, If clinical information is needed please be able to supply. Prior tests lab work and or imaging studies performed related to this diagnosis. The notes from the patient s last visit related to the diagnosis. Type and duration of treatment performed to date for the diagnosis. Clinical information may be uploaded electronically via the Provider Portal. Prior Authorization Outcomes, All requests are processed within 2 business days. after receipt of all necessary clinical information. Authorizations are typically good for 60 days from. Approved Requests the date of determination, Highmark will honor existing prior authorizations for.
continuity of care on claims for advanced imaging, cardiology services which overlap during the. transition to the new program, Faxed to ordering provider. Delivery Mailed to the member, Information can be printed on demand from the. Highmark provider web portal, Denied Requests Communication of denial determination. Communication of the rationale for the denial, How to request a Peer Review for commercial.
Faxed to the ordering provider and, Delivery Mailed to the member. Information can be printed on demand from the, Highmark provider web portal. Prior Authorization Outcomes Commercial, Additional clinical information can be provided. Reconsiderations without the need for a physician to participate. Must be requested on or before the anticipated date. of service, Commercial members only, If a request is denied and requires further clinical. Clinical Consultations discussion for approval we welcome requests for. clinical determination discussions from referring, physicians In certain instances additional.
information provided during the consultation is, sufficient to satisfy the medical necessity criteria for. Clinical Consultations can be scheduled at a time, convenient to your physician. Prior Authorization is required for certain advanced imaging and Cardiology services which are listed on the left hand side of the slide Modalities which previously did not require Prior Authorization but will now require Prior Authorization effective January 1st are bolded Those new modalities are Nuclear medicine

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