We contract with eviCore healthcare (eviCore) to manage the Advanced Imaging Services (AIS) provided to our members through prior authorizations (PA).

Through our Radiology Imaging Program, eviCore manages the AIS provided to our members through PA with providers. Through this program, eviCore:

• Helps ensure that the radiology/imaging services provided are appropriate.
• Provides clinical consultation to our participating health care professionals.
• Assists in the scheduling of radiology/imaging services.

The information below was last reviewed on July 24, 2023.

Q. What is eviCore healthcare?
A. eviCore is a specialty benefit management company that manages the quality and use of outpatient diagnostic and cardiac imaging, radiation therapy, pain management, spine surgery and other services. eviCore ensures that every treatment and test is medically necessary and appropriate for the individual patient.

Q. What are the AIS?
A. The AIS included in this program are:

• CT/CTA scans
• MRI/MRAs
• PET scans
• Nuclear medicine studies, including nuclear cardiology

Q. Who is responsible for obtaining a PA?
A. It is the ordering provider's (i.e., Primary Care Provider or specialist) responsibility to contact eviCore to obtain a PA for AIS. eviCore will not accept a request for a PA from the rendering provider. The rendering provider is responsible for verifying the status of PA prior to administering services. Providers can check the status of a PA by visiting eviCore.com, 24 hours a day, seven days a week, or by calling eviCore at 1-866-496-6200, Monday through Friday, 7 a.m. to 7 p.m., Eastern Time (ET), and Saturday and Sunday, 9 a.m. to 5 p.m., ET.

Q. Which products require a PA?
A. A PA is required for members enrolled in Horizon NJ Health or Horizon NJ TotalCare (HMO D-SNP). PAs do not apply to radiology/imaging services rendered during ER visits or inpatient stays.

Q. Who can an office contact to verify if a PA is required?
A. To verify if a PA is required, visit eviCore.com, 24 hours a day, seven days a week. You may also call eviCore at 1-866-496-6200, Monday through Friday, between 7 a.m. and 7 p.m., ET, and Saturday and Sunday, between 9 a.m. and 5 p.m., ET.

Q. Does eviCore allow for upgrades/downgrades to approved procedures?
A. Ordering providers can upgrade or downgrade a procedure before or after it is performed.

The following categories of requests to change a CPT® code from the ordering provider or the site will be authorized immediately via the CPT Change Tool regardless of if/when the exam was performed, as long as the anatomic (area of the body) part is the same:

• All Computed Tomography (CT) exams: Any contrast change
• Magnetic Resonance Imaging (MRI) exams: Any contrast change
• All requests to change any nuclear study to the nuclear study CPT code including single- photon emission computerized tomography (SPECT)
• All MRI Breast exams:
  Unilateral to Bilateral (77058 to 77059)
  Bilateral to Unilateral (77059 to 77058)
• Any change in the range of Positron Emission Tomography (PET) scans (78811, 78812, 78813, 78814, 78815 and 78816)
• Any change in the range of Echo CPT (93303-93308)

Q. What services are available to providers through eviCore.com?
A. Providers and their office staff have access to:

• Tutorials: provide program overviews and processes
• Physician guidelines: display current evidence-based recommendations regarding imaging
• Eligibility lookup: indicates which members require PA
• Authorization requests: allow offices to initiate authorization requests (requires registration)
• Authorization lookup: displays the status of authorizations
• Downloadable forms: including fax submission forms

Q. What is the turnaround time for a PA?
A. General requests will be resolved within three business days if all necessary clinical information is supplied. General requests for Medicare Advantage plans/products will be resolved no later than 14 calendar days after receipt of the request.

Q. Are medically-urgent requests accepted?
A. Yes. eviCore accommodates medically-urgent requests (non-life-threatening requests that can wait up to 24 hours) for PA. Urgent cases are handled within 72 hours of receipt of all necessary clinical information. Please call eviCore at 1-866-496-6200 with urgent requests. Emergent cases should be directed to the nearest Emergency Room (ER). PA is not required.

Q. What if the provider does not agree with eviCore's determination?
A. Providers who do not agree with eviCore's determination may call eviCore's Physician to Physician Consultation Line at 1-866-496-6200, select option 1, then choose option 4. You can discuss the details of the case in question with an eviCore medical director. In most cases, clinical information is clarified during these discussions.

Q. Do the same rules apply if a radiology facility outside of New Jersey is used?
A. If the radiology facility is located within our local service area and participates with Horizon NJ Health/Horizon NJ TotalCare (HMO D-SNP), the provider will need to obtain PA from eviCore. Horizon NJ Health/Horizon NJ TotalCare (HMO D-SNP) local service area includes all New Jersey counties, counties in Delaware, New York and Pennsylvania that are contiguous to New Jersey, and Lehigh County, PA.

Q. How does the enhanced scheduling process work for AIS?
A. The enhanced AIS scheduling process is as follows:

1. The ordering provider's office contacts eviCore to request a PA by either:
   • Submitting a request on eviCore.com (available 24 hours a day, seven days a week)
   • Calling eviCore at 1-866-496-6200, Monday through Friday, 7 a.m. to 7 p.m., ET, and Saturday and Sunday, 9 a.m. to 5 p.m., ET
   • Faxing a completed fax submission form to 1-800-637-5204
2. eviCore will ask for relevant clinical information and history, including a completed fax submission form, clinical office notes, consultation reports and previous diagnostic reports.
3. eviCore will contact the member to schedule the procedure at a participating rendering location. When possible, eviCore will conduct a three-way call with the member, eviCore and the rendering location to facilitate the scheduling process. Members may also call eviCore directly at 1-866-969-1234 to schedule the approved procedure. Members will receive a letter from eviCore confirming the scheduled appointment. If the provider calls to start the case on Saturday or Sunday, the office will be advised to have the member call eviCore at 1-866-969-1234 on Monday to schedule the procedure.
4. Once the appointment is scheduled, eviCore will fax a notice to the provider's office. The notice will include the PA confirmation and the location where the imaging services will be performed.

Q. What is the Scheduling Line?
A. The Scheduling Line is a service provided by eviCore to Horizon NJ Health/Horizon NJ TotalCare (HMO D-SNP) providers and members to assist in scheduling radiology/imaging procedures for patients. The Scheduling Line improves patient access to imaging services by helping the patient identify the Horizon NJ Health/Horizon NJ TotalCare (HMO D-SNP) participating radiology/imaging facilities that most closely match their needs. Providers and members may call eviCore's Scheduling Line at 1-866-969-1234. eviCore's professional scheduling coordinators are available Monday through Friday, 7 a.m. to 7 p.m., ET; and 24 hours a day, seven days a week via fax. eviCore collects basic information, checks eligibility and connects members directly with the facility they select to schedule an appointment. eviCore provides the ordering provider and facility with a fax confirmation of the patient's appointment, along with the unique tracking number.

Q. Where can I get fax submission forms for this program?
A. You can obtain fax submission forms at eviCore.com or by calling eviCore at 1-866-496-6200, Monday through Friday, 7 a.m. to 7 p.m., ET, and Saturday and Sunday, 9 a.m. to 5 p.m., ET.

Q. Can members choose which facility will provide their radiology services?
A. Yes. Members may choose the facility to provide their radiology services. eviCore will facilitate the scheduling of their visit.

Q. What should ordering providers give patients to schedule radiology/imaging services?
A. Ordering providers should give their patients a completed radiology prescription with instructions to call eviCore. A tracking number is not required if the ordering provider issues a referral for managed care members. PA reviews are still required for AIS (MRI/MRA, CT/CTA, PET scans, nuclear medicine and nuclear cardiology).

Q. What if a member wants to schedule other non-AIS radiology services (e.g., mammograms, X-rays, etc.)?
A. Members may call eviCore's Scheduling Line at 1-866-969-1234 to schedule a procedure. A tracking number will be issued for all services scheduled through eviCore.

Q. What information should be provided to the scheduling line by the patient for non-AIS radiology imaging services?
A. The patient should have his or her Horizon NJ Health or Horizon NJ TotalCare (HMO D-SNP) member ID card and the completed radiology prescription form available to schedule the appointment.

Q. Is a referral still required for non-AIS procedures?
A. No. Referrals are not required for radiology/imaging services rendered at non-hospital (freestanding) facilities or in the outpatient department of a participating hospital, as long as the services are scheduled through the Scheduling Line. The tracking number replaces the need for a referral. PA reviews are still required for AIS (MRI/MRA, CT/CTA, PET scans, nuclear medicine and nuclear cardiology).

Q. Where can I get more information on Horizon NJ Health/Horizon NJ TotalCare (HMO D-SNP)'s coding logic, claim edits and multiple procedure bundling for radiology/imaging services?
A. Our coding logic is based on the Centers for Medicare & Medicaid Services' (CMS) National Correct Coding Initiative (NCCI) and the Deficit Reduction Act of 2005. For more information on Horizon NJ Health's coding logic, claim edits and multiple procedure bundling for radiology/imaging services, visit horizonNJhealth.com/for-providers/resources/eviCore-healthcare.

Q. Who should I call if I have questions about these programs?
A. Call eviCore directly at 1-866-496-6200, Monday through Friday, 7 a.m. to 7 p.m., ET, and Saturday and Sunday, 9 a.m. to 5 p.m., ET, or you may contact your Network Specialist.

Q. Who will be notified of clinical determinations from eviCore?
A. Approvals letters will only go to the requesting providers. Adverse, Upheld or Overturn letters will be sent to both members and requesting providers only.

Q. Do the same rules apply for non-participating rendering sites in the state of New Jersey?
A. Yes, for members utilizing out-of-network sites, authorization must be obtained prior to services being rendered at a nonparticipating rendering site.