Oxford has engaged eviCore healthcare to perform initial reviews of requests for pre-certification.
eviCore healthcare has established an infrastructure to support the review, development, and implementation of comprehensive outpatient imaging criteria. The radiology and cardiology evidence-based guidelines and management criteria are available on the eviCore healthcare website.
eviCore healthcare handles all pre-certification requests. To pre-certify a radiology or cardiology procedure, please contact eviCore healthcare.
Oxford also requires a minimum care provider accreditation and certification requirements for MRI, PET, CT nuclear medicine studies.
More detailed information can be found on OxfordHealth.com > Providers (or Facilities) > Tools and Resources > Medical Information > Radiology & Radiation Therapy Information > Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement.
- Online: evicore.com; or
- Phone: 877-PREAUTH | 877-773-2884.
Imaging Requiring Prior Authorization
The referring care provider is responsible for contacting eviCore healthcare to request prior authorization and to provide sufficient history to verify the appropriateness of the requested services.
Our policy does not permit prior authorization requests from persons or entities other than referring care providers.
Radiology Prior Authorization Policy for Urgent Cases
It is the imaging facility’s responsibility to confirm before providing service that eviCore has issued an authorization number. In the case of urgent examinations, or in cases in which, in the opinion of the attending care provider or other health care professional, a change is required from the authorized examination, and the eviCore healthcare offices are unavailable, you may perform the services, and you may request a new or modified authorization number.
You must make the request within two business days of the service date through the Imaging Care Management department for Radiology. You should make the request immediately if the eviCore healthcare offices are available.
eviCore will review the clinical justification for the request using the same criteria as a routine request. See the How to Contact Oxford Commercial section for additional information.
Oxford has engaged eviCore healthcare to perform initial reviews of requests for pre-certification of for echocardiogram, stress echocardiogram, cardiac nuclear medicine studies, cardiac CT, PET and MRI and cardiac catheterizations procedures. eviCore healthcare has established correct coding and evidence-based criteria to determine the medical necessity and appropriate billing of cardiology services.
The cardiology evidence-based criteria and management criteria are available on the eviCore healthcare website at evicore.com. Oxford continues to be responsible for decisions to limit or deny coverage and for appeals.
The utilization review process involves matching the patient clinical history and diagnostic information with the approved criteria for each imaging procedure requested. Qualified health care providers, including board certified radiologists and cardiologists, make utilization review decisions for cardiac based diagnostic procedures. eviCore may assign data collection for clinical certification of imaging services to non-medical personnel working under the direction of qualified health care providers.
You will receive communication of review determinations for non-urgent care by fax/telephone within two business days of receiving all the necessary information. For urgent requests, eviCore will communicate their findings for medical necessity within 24 hours of receiving all information needed to make that decision.
For members, eviCore accepts requests for retrospective clinical certification review of medically urgent care up to two business days after the care has been given for radiology and 15 days for cardiac catheterization, if the services are performed outside eviCore healthcare’s hours of operation and rendered on an urgent basis. eviCore will make retrospective review decisions within 30 business days of receiving all of the necessary information. If your request is not authorized, they will send a review determination in writing to the member and the requesting care provider within five business days of the decision.
All authorization reference numbers are issued at the time of approval. eviCore healthcare uses the reference CPT code as the last five digits of the authorization number. We require the submission of clinical office notes for specific procedures. Clinical notes include the patient’s medical record and/or letters received from specialists.
Radiation Therapy Procedures
Oxford has engaged eviCore healthcare to perform prior authorization and medical necessity reviews for all outpatient radiation therapy services (Oxford continues to be responsible for decisions to limit or deny coverage and for appeals.)
eviCore handles all pre-certification requests. The following radiation therapy treatments require prior authorization through eviCore healthcare for Oxford products:
- Ionizing radiation
- Conventional external beam radiation therapy (CRT)
- Three-dimensional conformal radiation therapy (3D CRT)
- Intensity modulated radiation therapy (IMRT)
- Image-guided radiation therapy (IGRT)
- Proton beam therapy (PBT)
- Selective Internal Radiation Therapy (SIRT)
- Stereotactic radiosurgery (SRS)
- Other emerging therapies that use ionizing radiation to treat cancer such as hyperthermia and neutron beam therapy
Find a complete list of radiation therapy treatments requiring prior authorization through eviCore healthcare for Oxford products on: OxfordHealth.com > Providers (or Facilities) > Tools and Resources > Medical Information > Medical and Administrative Policies > Medical and Administrative Policy Index > Radiation Therapy Procedures Requiring Precertification for eviCore healthcare Arrangement.
eviCore healthcare has established correct coding and evidence-based guidelines to determine the medical necessity and appropriate billing of radiation oncology services. They carefully researched these guidelines. The guidelines are continually updated to keep consistent with the most current evidence-based guidelines and recommendations for the provision of radiation therapy from national and international medical societies and evidence-based medicine research centers.
Oxford New Jersey Small, Municipality, and School Board Members
Radiology and Radiation Therapy Procedures
eviCore healthcare will perform a medical necessity review before rendering the services. To obtain prior authorization for a course of radiation therapy, contact eviCore healthcare.
We require the submission of clinical office notes for specific procedures if a medical necessity review/ utilization review is not conducted before the services were performed. Clinical notes include the patient’s medical record and/or letters received from specialists.
Supporting clinical information provided by the ordering care provider must contain the ordering/referring care provider’s name and signature, address, phone and fax numbers, specialty, tax identification number and information such as:
- Reason for the procedure performed;
- Patient’s signs and symptoms;
- Treatment, including type and duration;
- Previous studies for the specific medical issue; and
- Any other pertinent clinical information to determine medical necessity.
Note: eviCore policy does not permit prior authorization requests from persons or entities other than the following:
- Radiology services: The referring physician is responsible for providing medical documentation showing clinical necessity for the requested or rendered outpatient radiology procedure, for pre- and post-service review.
- Radiation Therapy services: The rendering radiation therapist is required to request prior authorization. Follow the Physician Worksheets to help ensure you provide the right information to determine the medical necessity of the requested services.
Certain Oxford products require referrals for radiology or radiation therapy from the member’s PCP. If your patient is enrolled in one of these benefit plans, they will be required to obtain a referral before seeing you for an initial visit.
We will continue to process claims from participating care providers for radiation therapy services. You will receive payment directly from us.
You cannot balance bill the member if a claim is denied because medical necessity was not demonstrated. We will offer all appropriate rights of appeal for any service that is not approved for payment.
Cardiology, Cardiac Catheterization, Echocardiogram and Stress Echocardiogram
Oxford has engaged eviCore healthcare to perform medical necessity review for outpatient cardiac imaging (CT, PET, MRI and Nuclear medicine), cardiac catheterizations, echocardiogram and stress echocardiogram studies. When services are provided in the emergency room, observation unit, urgent care facility, or during an inpatient stay, prior authorization is not required.
eviCore healthcare performs a medical necessity review before you deliver the services. To get a prior authorization for a course of radiation therapy, contact eviCore healthcare.
- Online: evicore.com
The referring care provider is responsible for providing medical documentation showing clinical necessity for the requested procedure (for review before service). eviCore policy does not permit prior authorization requests from
persons or entities other than referring care providers.
For post-service reviews (a review after service was provided) the referring care provider is still responsible for providing medical documentation showing clinical necessity for the procedure performed.
We require you to submit clinical office notes for specific procedures if a medical necessity review/utilization review is not conducted before you provide services. Clinical notes include the patient’s medical record and/or letters received from specialists. Supporting clinical information provided by the ordering care provider must contain the ordering/referring care provider’s name and signature, address, phone and fax numbers, specialty, tax identification number and information such as:
- Reason for the procedure performed
- Patient’s signs and symptoms
- Treatment, including type and duration
- Previous studies for the specific medical issue
- Any other pertinent clinical information to determine medical necessity
You can find a list of codes that will require prior authorization online at OxfordHealth.com > Providers or Facilities > Tools & Resources > Medical and Administrative Policies > Medical & Administrative Policy Index > Services Requiring Prior Authorization.
Prior authorization requirements can be verified through one of the following options:
- Care providers can call the number on the back of the member’s health care ID card and check eligibility.
- Use the Diagnostic Heart Catheterization worksheets found online at eviCore.com to help ensure you have the required information to initiate the prior authorization process.
- For more information, including the clinical criteria, please visit eviCore.com > eviCore Solutions > Cardiology > Cardiology Tools and Criteria.
A list of Current Procedural Terminology (CPT®) codes requiring medical necessity review is available on:
OxfordHealth.com > Providers or Facilities > Tools & Resources > Medical Information.
The clinical criteria consistent with existing UnitedHealthcare and Oxford policy are available on eviCore.com.
Infertility Utilization Review Process
Oxford has delegated Optum, a UnitedHealth Group company, to perform reviews for infertility services under their Managed Infertility Program (MIP) for all Oxford Commercial members with an infertility benefit. Optum uses MIP to promote both quality of care and continuity of service by supporting patients through every aspect of the infertility process.
Optum’s infertility nurse case managers provide support and help patients in make informed decisions about their infertility treatment and care through: treatment education, considerations in choosing where to obtain care, and assistance in navigating the health care system.
For Oxford products, the rendering care provider is required to request prior authorization and/or notification of services. Make this request using the Managed Infertility Program Treatment form. Provide sufficient information to determine the medical necessity of the requested services.
Optum has been diligent in their research to help ensure the clinical policies and guidelines they are using are consistent with best practices and state mandates.
You can get the Managed Infertility Program (MIP) Prior Authorization template :
- Online, after logging onto myoptumhealthcomplexmedical.com, or
- Calling OptumHealth at 877-512-9340 or
- Sending an email to: MIP@optum.com.
Physical and Occupational Therapy
Oxford has delegated certain administrative services related to outpatient physical and occupational therapy services to OptumHealth Care Solutions. Hospital outpatient treatment facilities, outpatient facilities at or affiliated with rehabilitation hospitals are considered outpatient settings for physical and occupational therapy.
All physical and/or occupational therapy visits require utilization review and an authorization, including the initial evaluation. After registering on myoptumhealthphysicalhealth.com, click on the ‘Forms’ link and locate the Patient Summary Form.
The treating care provider or health care professional must submit a Patient Summary Form to OptumHealth. They can submit the completed form through the OptumHealth website myoptumhealthphysicalhealth.com. Send the forms within three days of initiating treatment. The forms must be received within 10 days from the initial date of service indicated on the form. OptumHealth adjusts the initial payable date when they receive the forms outside of the 10-day submission requirement.
The Patient Summary Form must include the initial visit. If OptumHealth Care Solutions does not receive the required form(s) within this time frame, they deny the claim. OptumHealth Care Solutions reviews the services requested for medical necessity.
After the initial approved visits have occurred, if a patient’s care requires additional visits or more time than was approved, you must submit a new Patient Summary Form with updated clinical information.
Note: Prior authorization is not required for certain groups.
OrthoNet, a musculoskeletal disease management company is our network manager for most musculoskeletal services. OrthoNet’s orthopedic division will perform utilization management review of requested services to ensure they meet approved clinical guidelines for medical necessity.
OrthoNet will conduct the review by determining medical necessity and medical appropriateness, and to initiate discharge planning, as appropriate. OrthoNet will base the results on the clinical information and some or all of the following criteria/tools:
- Member benefits
- Oxford medical and reimbursement policies
- MCG Care Guidelines, 21st edition, 2017 (Inpatient Care)
Services performed by the following specialties (participating and non-participating) are subject to utilization review by OrthoNet’s orthopedic division regardless of the diagnosis:
- Orthopedic Surgery
- Pediatric Orthopedic Surgery
- Hand Surgery
- Physical Medicine Rehabilitation
OrthoNet’s orthopedic division manages services provided by the facilities below (participating and non-participating) when billed together with certain ICD-10 codes:
- Acute Care Hospital
- Ambulatory Surgery
- Other Ancillary Facility
- Home Health Care
- Physical Rehabilitation Hospital
- Physical Rehabilitation Facility
- Skilled Nursing Facility
For a complete list of orthopedic diagnosis codes, or for more information on Oxford’s arrangement with OrthoNet, refer to OxfordHealth.com > Providers or Facilities > Tools & Resources > Medical and Administrative Policies > Medical & Administrative Policy Index > Orthopedic Services.
OptumHealth Care Solutions currently manages our chiropractic benefit. To receive the standard chiropractic benefit coverage, members must obtain an electronic referral from their PCP. PCPs perform the customary initial comprehensive differential diagnosis with the necessary and appropriate work-up.
You can request a chiropractic referral for a maximum of one visit within 180 days (six months). Participating chiropractors must complete and submit Patient Summary Forms to OptumHealth Care Solutions for services performed.
They can submit the Patient Summary Forms through the OptumHealth Care Solutions website at myoptumhealthphysicalhealth.com. They must submit the form within three business days and no later than 10 business days following the member’s initial visit or recovery milestone. The Patient Summary Form must include the initial visit. If OptumHealth Care Solutions does not receive the required form(s) within this time frame, they deny the claim.
Once they receive the forms, OptumHealth Care Solutions will review the services requested for medical necessity, and will make any denial determinations.
If a member’s care requires more visits or time than was approved, you must submit a new Patient Summary Form with updated clinical information after the initially approved visits have occurred.
According to your contract with Care Solutions, the member may not be balance billed for any covered service not reimbursed if you do not submit the Patient Summary Form, or for those services which do not meet medical necessity or coverage criteria. However, you may file an appeal.
Only members who have the alternative medicine rider have coverage for acupuncture. If a member does not have the alternative medicine rider, we deny all requests to cover acupuncture, even if a letter of medical necessity has been
Acupuncture services must be rendered in-network and performed by one of following care provider types:
- Participating licensed acupuncturist (LAC)
- Participating licensed naturopaths
- Participating care provider (MD or DO) who has been credentialed as physician acupuncturist
Pharmacy Management Programs
The pharmacy benefit plan includes a dynamic medication list, referred to as the Prescription Drug List (PDL), and various clinical drug utilization management programs. We base these programs on FDA-approved indications and medical literature or guidelines.
The PDL contains medications in three tiers; Tier 1 is the lowest cost option and Tier 3 is the highest cost option. Some of our groups have a 4-tier benefit design.
To help make medications more affordable, consider whether a Tier 1 or Tier 2 alternative is appropriate if the member is currently taking a Tier 3 medication.
We perform ongoing reviews of the PDL and updated it at least twice per year. Medications requiring notification or prior authorization are noted with a “PA”, medications that require step therapy are noted with “ST” and supply limits with “SL”.
PDL Management Committee and the Pharmacy & Therapeutics Committee
The UnitedHealthcare PDL Management Committee, a group of senior care providers and business leaders, makes tier decisions and changes to the PDL based on a review of clinical, economic and pharmacoeconomic evidence.
The UnitedHealthcare National Pharmacy and Therapeutics Committee (P&T) is responsible for evaluating and providing clinical evidence to the PDL Management Committee to help them assign medications to tiers on the PDL. The information provided by the P&T Committee includes, evaluation of a medication’s place in therapy, its relative safety and its relative efficacy.
The P&T Committee also reviews and approves clinical criteria for prior authorization and step therapy programs, and supply limits. In addition to medications covered under the pharmacy benefit, the P&T Committee is responsible for evaluating clinical evidence for medications, which require administration or supervision by a qualified, licensed health care professional.
The P&T Committee is comprised of medical directors, network care providers, consultant physicians, clinical pharmacists and pharmacy directors.
For more information regarding Oxford’s Pharmacy Management Program, go to oxhp.com.
Quality Management and Patient Safety Programs Drug Utilization Review (DUR)
We receive the majority of prescription claims electronically for payment. Within seconds our systems record the member’s claim and review the past prescription history for potential medication-related problems.
DUR helps review for potentially harmful medication interactions,inappropriate utilization and other adverse medication events to maximize therapy effectiveness within the appropriate medication usage parameters.
There are two types of DUR programs: concurrent and retrospective.
Concurrent Drug Utilization Review (C-DUR)
The C-DUR program performs online, real-time DUR analysis at the point of prescription dispensing. This program screens every prescription before dispensing for a broad range of safety and utilization considerations.
C-DUR uses a clinical database to compare the current prescription to the member’s inferred diagnosis, demographic data and past prescription history. The C-DUR program uses criteria to identify potential inappropriate medication consumption, medical conflicts or dangerous interactions that may result if the prescription is dispensed.
If the C-DUR identifies a potential problem, it notifies the dispensing pharmacist by sending either a soft alert (warning message) or a hard alert (a warning message also requiring the pharmacist to enter an override).
The dispensing pharmacist uses their professional judgment to determine appropriate interventions, such as contacting the prescribing care provider or other health care professional, discussing concerns with the member and dispensing the medication.
Retrospective Drug Utilization Review (R-DUR)
The R-DUR program involves a quarterly review of prescription claims data to identify patterns in prescribing or medication utilization suggesting inappropriate or unnecessary medication use.
The program uses a clinical database to review patient profiles for potential over-or under-dosing as well as duration of therapy, potential drug interactions, drug-age considerations and therapy duplications.
Our care providers and other prescribers receive a patient specific report quarterly outlining the opportunities for intervention and asking them to respond to specific issues and concerns.
Prescription Medications Requiring Prior Authorization (Subject to Plan Design)
Based on the member’s benefit plan design, select high-risk or high-cost medications may require advance notification (PA) to be eligible for coverage. We may ask you to provide information explaining medical necessity and/or past therapeutic failures.
A representative will collect all pertinent clinical data for the service requested. If we can’t approve the prior authorization, a pharmacist or medical director, in keeping with state regulations, will make the final coverage determination. We will notify you and the member of the decision.
Step Therapy (Subject to Plan Design)
Certain medications may be subject to step therapy (ST), also referred to as First Start for New Jersey members.
The step therapy program requires a trial of a lower-cost, Step 1 medication before a higher-cost, Step 2 medication is eligible for coverage.
When a member presents a Step 2 medication at the pharmacy, our systems may automatically check the claims history to see if there is a Step 1 medication in the claims history. The medication may automatically process. If not, request a coverage review.
If we can’t approve the medication, a pharmacist or medical director, in keeping with state regulations, will make the final coverage determination and we will notify you and the member of the decision.
Supply Limits (Subject to Plan Design)
Some medications are subject to supply limits (SL). We base supply limits on FDA-approved dosing guidelines as defined in the product package insert and the medical literature or guidelines and data supporting the use of higher or lower dosages than the FDA- recommended dosage.
This program focuses on select medications or categories of medications that are high cost and/or are frequently used outside of generally accepted clinical standards.
When a pharmacist submits an online prescription claim, the online claims processing system compares the quantity entered with the allowable limits.
If the prescription exceeds the established quantity limits, we reject the claim and the pharmacist receives a message. The current supply limit for the medication is displayed in the message.
A subset of medications has coverage criteria available to obtain quantities beyond the established limit. For these medications, the pharmacist receives a message that includes the toll-free number to call for the coverage review.