Oncology and hematology prior authorization and utilization management
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Governs authorization requirements and referral to New Century Health (NCH) for oncology, hematology, radiation oncology, and related transplant chemotherapy services for Ambetter From Magnolia Health members; applies to adult and pediatric providers and membership.
No material clinical or coverage changes in this revision.
Services Requiring NCH Authorization
Covered with criteria
Covered when ALL of the following are met:
ALL of the following
- Infused or oral chemotherapy
- Hormonal therapeutic treatment
- Supportive agents and symptom management medications
- Radiation procedures: Brachytherapy, Conformal IMRT, SBRT, IGRT 3D
Exclusions
The following are explicit exclusions from NCH scope and should be handled as noted:
Diagnosis and Billing Codes
| C00-D09, D37-D44, E34.0 | Cancer diagnosis codes scope |
| D45-D49, D61.81, D61.2, D63.0, D63.8 | Hematology diagnosis codes scope |
| D72.9, D73.81, D73.9, D75.1, D75.81, D75.82 | Additional hematology-related diagnosis codes referenced |
| R11 | Nausea & vomiting (N&V) code referenced |
Authorization Requirements and Submission Process
Authorization required for oncology/hematology services
Authorization is required for infused and oral chemotherapy, hormonal therapeutic treatment, supportive agents, symptom management medications, and specified radiation oncology procedures when the member has an oncology/hematology diagnosis.
- Applies to adult and pediatric providers and membership
- Radiation procedures requiring authorization include Brachytherapy, Conformal IMRT, SBRT, IGRT 3D
Submit NCH Cancer Treatment Request and allow 5 business days
Physician offices must complete and submit the NCH Cancer Treatment Request to obtain preauthorization and should allow 5 business days for the authorization process. Use the NCH provider web portal (https://my.newcenturyhealth.com) or contact NCH by phone (888-999-7713) with options: Medical Oncology – Option 1, Radiation Oncology – Option 2, Peer-to-Peer – Option 6 (telephonic intake Option 5). NCH hours: 7:00 AM – 7:00 PM CST, Monday–Friday.
- Complete and submit NCH Cancer Treatment Request for preauthorization
- Allow 5 business days for processing
- Phone: 888-999-7713 (Options: Medical Oncology 1, Radiation Oncology 2, Peer-to-Peer 6 / Telephonic Intake 5)
- Portal: https://my.newcenturyhealth.com
Transplant chemotherapy: route prior to mobilization to NCH; at mobilization to Ambetter transplant unit
For transplant-related chemotherapy, send all chemotherapy regimen requests to New Century Health prior to mobilization. Beginning with mobilization, route all authorization requests for transplant-related chemotherapy to the Ambetter From Magnolia Health transplant unit.
- Prior to mobilization: submit regimen requests to New Century Health
- Beginning with mobilization: submit transplant-related chemotherapy authorization requests to Ambetter From Magnolia Health transplant unit
Retrospective and out-of-scope requests must be appealed to the Health Plan
Retrospective (retro) authorizations are out of scope for New Century Health and should be appealed with Ambetter From Magnolia Health; out-of-scope requests will be forwarded to the Health Plan.
- Do not submit retro authorizations to NCH—appeal retro requests with Ambetter From Magnolia Health
- Out-of-scope requests will be forwarded to the Health Plan
Definitions and Scope Notes
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