eviCore healthcare

Horizon NJ Health partners with eviCore healthcare (eviCore) to manage Advanced Imaging Services for our members through Prior Authorizations/Medical Necessity Determinations (PA/MND) with providers. eviCore helps to ensure our members receive appropriate radiology/imaging services, provides clinical consultation to our participating healthcare professionals and assists in the scheduling of radiology/imaging services. The Advanced Imaging Services included in this program are CT/CTA, MRI/MRA, PET and Nuclear Medicine studies (including Nuclear Cardiology).

As of January 1, 2020, eviCore provides Utilization Management for Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) members. Please note, eviCore began to accept authorization requests on December 16, 2019 for dates of service beginning January 1, 2020.

eviCore manages Advanced Imaging Services for our members through PA/MND with providers.

eviCore administers our Cardiology Imaging program by using evidence-based criteria. They ensure requests for advanced cardiac imaging meet quality standards recommended by organizations such as the American College of Cardiology, American Heart Association and Heart Rhythm Society. eviCore identifies the most appropriate cardiac imaging study based on the patient’s medical and prior imaging history.

Radiation Therapy
eviCore implements our Pre-service MND program to ensure that the radiation therapy services provided to our members are consistent with nationally-recognized clinical standards. The Radiation Therapy program addresses a patient’s specific disease state, stage and treatment goals and offers clinicians the necessary flexibility to render appropriate quality care in a timely manner.

Please note that eligibility and participation may vary based on line of business; therefore, all providers should check eligibility and benefits prior to performing any services related to this program.

Prior authorization will be required for the following non emergent outpatient radiology procedures:

Prior authorization applies to services that are:

  • Outpatient
  • Elective/non-emergent

Prior authorization through eviCore does not apply to services that are performed in:

  • Emergency Room
  • Inpatient facilities
  • 24-hour observation

Prior authorization is required for members enrolled in the following programs:

  • Medicaid Managed Care
  • NJ FamilyCare
  • Horizon NJ TotalCare (HMO D-SNP)
  • Managed Long Term Services & Supports (MLTSS)

For the list of eviCore CPT codes, review the CPT Code List.

Providers and/or staff can request prior authorization in one of the following ways:

Web Portal: The quickest and most efficient way to request prior authorization is by using the eviCore portal at eviCore.com, which is available 24 hours a day, seven days a week.

Call Center: eviCore’s is available from 7 a.m. to 7 p.m. Providers and/or staff can request prior authorization and make revisions to existing cases by calling 1-866-496-6200.

For Multiple Procedure Payment Reduction rules, view the Bundling Rules for Medicaid.

View 2022 Multiple Procedure Payment Reduction rules here.

View 2022 Contrast Agents and Radiopharmaceuticals rules here.

For more information on eviCore, refer to the frequently asked questions.

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