Radiology Utilization Management

We are building on our existing utilization management (UM) program efforts and have selected an experienced third-party vendor, eviCore (formerly known as CareCore National, LLC (CCN), to administer our new radiology management program.

Our radiology management program will:

  • Drive quality improvement.
  • Enhance provider service through better coordination and management of treatment modalities, sites of service, and medical necessity determinations.

Prior Authorization Requirement

Effective April 1, 2014, the provider must obtain a prior authorization through eviCore before providing the following services. A complete list of services requiring authorization is available here. The list will indicate the corresponding UM processor for each service at the procedure code level.

  • MRI (including Contrast & 3DI)
  • CT (including Contrast & 3DI)
  • PET & PET/CT

Services rendered in an inpatient facility, emergency department, or urgent care center does not require prior authorization.

Please do not submit requests for members who belong to Community Health Center Network (CHCN), Children's First Medical Group (CFMG), and Kaiser Permanente (KP). Please adhere to the individual authorization requirements of the medical groups for your patients who are assigned to one.

Please note:

  • Failure to obtain a prior authorization for the above services by the servicing provider will result in claim non-payment and will become provider liability. As the claim is non-payable due to non-compliance by the provider, this will not be considered a Non-Covered Service. Our members may not be balanced billed, whether or not a "member consent form" for Non-Covered Services has been signed.
  • eviCore only allows retroactive authorizations post two days from date of service.

Initiating an Authorization

An authorization can be initiated by the servicing physician or other health care professional by phone at 1-855-774-1316, fax at 1-800-540-2406 or through eviCore's online web tool at www.carecorenational.com. Phone initiations are recommended for urgent cases whereas the web tool is recommended for routine requests.

The following minimum information will be required to initiate an authorization:

  • Patient’s name
  • Diagnosis code
  • Patient’s date of birth
  • Patient’s member number
  • Patient’s address and phone number
  • Requested service and/or CPT code
  • Any clinical information pertaining to the requested service
  • Physician or other health care professionals National Provider Identifier (NPI)

An authorization/notification number will be given for all authorizations that are consistent with evidence-based clinical guidelines. The format will be an alpha code followed by numeric values and the CPT code requested (e.g., A012123456-70450).

 

Verifying an Authorization

To verify the status of an existing prior authorization/notification request, you will be able to go online to the Authorization lookup (available seven days a week, 24 hours a day) or contact eviCore at 1-855-774-1316.

eviCore will provide full utilization management, including receiving/processing prior authorization requests for:

  • Eligibility verification
  • Benefit interpretation
  • Appropriateness of service
  • Site of service management
  • Medical necessity determinations

Additional Information