Changes in eviCore authorization requirements

Services that no longer require authorization through eviCore. Effective immediately, the following procedures no longer require authorization by eviCore healthcare:

• "Add-on" codes do not require prior authorization. Prior authorization is required only for the primary code. A separate authorization is not needed to bill BCN for add-on codes if there is a valid authorization on file for the primary code. Claims submitted to BCN for add-on codes without authorization for the associated primary code will not be reimbursed. The affected add-on procedure codes are *0159T, *0190T, *19297, *33225, *49412, *75565, *77293, *78020, *78730, *93320, *93321, *93325, *93352, and *93462.


• Select radiation therapy codes also do not require prior authorization. Click here to see a list of the affected radiation therapy codes.


• The unlisted radiation therapy procedure code *77799 is no longer managed by eviCore. Requests to authorize this procedure should be submitted to BCN Care Management.

Services that do require authorization through eviCore. When multiple radiology and cardiology services are to be performed, a separate authorization is needed though eviCore for each procedure code. This occurs when there are both primary and secondary procedures being performed and the secondary codes are not add-on codes. An example is when procedures associated with both the following codes are being performed and both require prior authorization: *78459 and *78491.

Claims information. BCN's systems are being reconfigured to accommodate these changes retroactive to Oct. 1, 2015. Once our systems have been updated, any claims that were denied for no authorization that, per this notice, were for procedures that no longer require prior authorization will be reprocessed. There is no need to re-bill these claims.

Updated documents are available. Refer to the updated list of Procedures that require clinical review by eviCore healthcare. This list, along with additional information, is available on the Procedures Managed by eviCore for BCN Web page on this website.

Reminder. October 1, 2015, was the effective date on which eviCore healthcare (formerly CareCore National) began performing clinical review for select cardiology, radiology and radiation therapy services. This involves select non-emergent outpatient services when performed on or after Oct. 1, 2015, in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMO^SM (commercial) and BCN Advantage^SM members.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.