Radiation Therapy Management Program
To help ensure our members are receiving the most clinically appropriate care, the Benefit Funds have partnered with eviCore healthcare (formerly CareCore National) to review certain radiation therapy services. Starting April 1, 2016, you must contact eviCore for prior authorization of radiation therapy services associated with the CPT/HCPCS codes on the list below.
In addition to prior authorization, eviCore will review all radiation therapy procedure claims for coding accuracy and medical necessity. Refer to the procedure category and CPT/HCPCS code range on the list below. We urge you to update your claims submission systems and coding practices accordingly to avoid payment delays or unnecessary denials.
If you receive an adverse payment decision as a result of eviCore’s code policies, you may submit a request for claim review directly to eviCore. You should fax requests to (844) 545-9214 or mail requests to eviCore healthcare, 400 Buckwalter Place Blvd., Bluffton, SC 29910. Include a copy of the claim, eviCore correspondence, information about the determination to be reviewed and any pertinent documentation to support your request for claim review.
How to Request Prior Authorization for Radiation Therapy Services
- Online: Register for free at eviCore (formerly CareCore) and log into the “Ordering Provider Login.” You may be able to receive an immediate authorization if your patient meets the coverage criteria.
- By phone: Call eviCore toll-free at (888) 910-1199, Monday through Friday, from 7:00 am to 7:00 pm in all time zones.
- For urgent requests: If services are required in less than 48 hours due to medically urgent conditions, please call eviCore’s toll-free number at (888) 910-1199 for expedited authorization reviews. Be sure to tell the eviCore representative that the authorization is for medically urgent care.
Note: The initial authorization request will NOT be accepted via FAX by eviCore.
Note: eviCore will not accept post-service authorization requests.
If you have any questions about this program, please contact your Provider Representative, or call our Provider Relations Call Center at (646) 473-7160, Monday through Friday, from 8:00 am to 6:00 pm.
eviCore healthcare Radiation Therapy Pathway Announcement
In an effort to continue to refine their processes, effective Friday April 14, 2017 eviCore has updated the Cervical, Endometrial, Pancreatic, Skin, Gastric, Rectal, Testicular, Gallbladder, Bile Duct, Hepatobiliary, Liver, Adrenal, Bladder, Kidney, Ureter, Extracranial Oligometastases, and Prostate Cancer worksheet questions for case build. The worksheet questions updates are based on ongoing efforts to develop the overall quality and consistency of the worksheets by further tailoring and improving the questions. The new worksheet questions will reflect current case build practices for all other cancer types. The updated interactive PDF versions of the worksheets are posted online on eviCore’s website.
- eviCore Quick Reference Guide — A one-page guide on how to submit a prior authorization request, along with some contact information.
- Frequently Asked Questions (FAQs)
- Radiation Therapy Clinical and Coding Guidelines
- Radiation Therapy Tools and Criteria
- Radiation Therapy Clinical Documentation Requirements
- Radiation Therapy Prior Authorization and Claims Studio Procedure Codes