eviCore authorization requirements change for pediatric members and for select procedure codes
The authorization requirements have changed for some procedures managed for BCN by eviCore healthcare.
Requirements for pediatric members. Effective immediately, cardiology and radiation therapy procedures no longer require prior authorization for pediatric members under 18 years of age (through 17 years of age) who have BCN HMOSM (commercial) and BCN AdvantageSM coverage.
Radiology services for pediatric members continue to require prior authorization for those procedure codes included on the list of Procedures that require clinical review by eviCore healthcare. Cardiology, radiation therapy and radiology services for adult members (18 years of age and older) that are included on the list continue to require prior authorization by eviCore.
BCN's referral requirements still apply and vary by region. Refer to the BCN Referral/Clinical Review Program for information on the referral requirements for your region.
Other requirements. Effective Jan. 1, 2016, services associated with the following procedure codes require prior authorization by eviCore healthcare:
- Radiology: CPT codes *74712, *78265 and *78266
- Radiation therapy: CPT codes *0394T, *0395T, *77767, *77768, *77770, *77771 and *77772
These are 2016 codes with the annual code updates for the American Medical Association and Healthcare Common Procedure Coding System. They are within the range of services currently managed by eviCore; they either replace 2015 codes or represent new or expanded codes that were made more specific for reporting purposes.
In addition, effective Oct. 1, 2015, services associated with the following procedure codes also require prior authorization by eviCore healthcare:
- Radiology: CPT codes *75635 and 77022
- Radiation therapy: CPT code *77014
These codes were included in the program implemented on Oct. 1, 2015, but were inadvertently not reflected on the list of procedures that require authorization by eviCore.
Documents to be updated. The following documents will be updated with these changes and will be available on this website by the end of January:
- Procedures that require clinical review by eviCore healthcare. Click eviCore-Managed Procedures to find this document.
- BCN Referral/Clinical Review Program. Click Clinical Review & Criteria Charts to find this document.
* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.
Posted: January 2016
Line of business: Blue Care Network