Utilization Management Program Radiology/Cardiology

Utilization Management Program Radiology/Cardiology

A complete list of codes requiring authorization through eviCore healthcare (eviCore) can be found on the eviCore site: healthplan/meridian_wellcare

Authorization Required

All outpatient, non-emergent, and elective procedures, including:

Radiology Services: MRI/MRA CT scan Positron emission tomography (PET) scan PET/CT scan Nuclear medicine

Cardiology Services: Nuclear stress testing Cardiac imaging Cardiac PET Stress echocardiography Echocardiography transthoracic Diagnostic heart catheterization Cardiac MRI Cardiac CT

Urgent Requests

When a service is required due to a medically urgent condition, the requesting provider's office must call eviCore at 888-333-8641 or request an authorization via the eviCore portal at . If you are calling to initiate the prior authorization (PA), please indicate that the notification is for medically urgent care. After the receipt of all necessary clinical information, eviCore will review the case(s) within 72 hours for MeridianHealth, MeridianChoice, MeridianComplete, and MeridianCare. In most cases, where requisite information is provided in the initial request, a decision is rendered and communicated within one business day.

Authorization Requirements

To ensure the authorization process is as quick and efficient as possible, we recommend that the provider's office submitting requests have the following:

Member's insurance information Member's name, ID number, and DOB Ordering or requesting provider's information

(name, address, TIN/UPIN/NPI) Servicing provider's information (name, address

where test is to be performed) CPT and ICD-10 code Patient history, including signs and symptoms Results of previous studies and treatments, if applicable Treatment plan Lab medical necessity review requires relevant patient

and family history, including onset dates

Authorizations

An authorization number will be faxed to the requesting provider and mailed to the member upon approval. eviCore will approve the specific facility performing the procedure and the CPT code(s) for the services.

Authorization Not Required

Inpatient radiology Procedures performed in the emergency room (ER) 23-hour observation X-rays Obstetrical ultrasounds (OB US)

Contact eviCore for changes to the facility or study.

It is the servicing facility's responsibility to confirm that the requesting provider completed the prior authorization process for procedures if the servicing facility is not completing the authorization process itself. The quickest, most efficient way to obtain prior authorization is through the 24/7 self- service eviCore portal at . Log into your provider account then click "Clinical Certification."

When a case is initiated on the eviCore portal and meets clinical criteria, a real-time authorization may be received. Prior authorization can also be obtained via phone at 888-333-8641 or faxed to 800-540-2406. Standard requests will be processed no later than 14 calendar days for MeridianHealth, MeridianChoice, MeridianComplete, and MeridianCare.

Important! An authorization from eviCore does not guarantee claim payment. Services must be covered by the health plan and the member must be eligible at the time the services are rendered. Claims submitted for unauthorized procedures are subject to denial.

Please verify the member's eligibility with the health plan by contacting a Meridian representative at 888-4370606.

Authorization Denials

eviCore notifies the requesting provider of a denial and provides a rationale for the determination by fax. The member is notified by mail. This communication includes the line of business-specific appeal rights.

Utilization Management Program Radiology/Cardiology

We offer convenient methods to request authorizations:

Web Portal

The web portal remains the quickest, most efficient way to obtain information. After a one-time registration, you can initiate a case, view case/authorization details, verify eligibility, and more. The eviCore portal is available 24/7 at:



Web portal assistance:

portal.support@

Or call: 800-646-0418 (Option 2)

Phone

Contact us toll-free at 888-333-8641 Monday ? Friday, 7 a.m. to 7 p.m. For faster service, you will need all pertinent clinical information prior to calling.

The eviCore call center will be closed in observance of New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving and the day after, and Christmas Day. On-call clinical staff will be available in the event of an urgent request. The web portal is available 24/7, 365 days a year.

Fax

Fax your requests to 800-540-2406. You will need to complete the appropriate clinical worksheet and include the office notes and previous imaging notes for the patient with the request.

Guidelines on the Web

To access the eviCore guidelines via the web, visit our site at the following link:



From there, you can access important information and resources:

Education tools Program overview Clinical guidelines and quick reference

guides Online forms

Implementation Site

The eviCore-Meridian implementation website contains web registration and submission information, comprehensive CPT code list, FAQ documents, quick reference guides (QRG), and other important resources that are kept up-to-date for your convenience:

healthplan/meridian_wellcare

Need Clinical Support?

If your case requires further clinical discussion for approval, we welcome requests for peer-to-peer discussions from requesting providers. For all plans, peer-to-peer discussions can occur at any point prior to the decision. For MeridianChoice and MeridianHealth, a peer-to-peer can be requested up to 10 days following the date of an initial denial. One of eviCore's medical directors can assist in a review of the medical necessity for a requested procedure. To request a peer-to-peer, call eviCore at 800-918-8924 Monday ? Friday, 7 a.m. to 7 p.m. and follow the prompts.

To request a peer-to-peer online, please visit the following direct link:

provider/request-a-clinical-consultation

Note: This is only for authorization discussion and providing additional clinical support for medical necessity. This is not where claim denials would be discussed. For claim denials, you must contact the health plan.

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