CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Prior Authorization for Advanced Imaging and Cardiology Services

Governs prior authorization requirements for outpatient, non-emergent, elective advanced imaging and cardiology procedures for Highmark BlueShield NENY members; identifies services that require authorization, how to request it, and exceptions.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Prior Authorization for Advanced Imaging and Cardiology Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from eviCore before performing outpatient non-emergent advanced imaging or cardiology procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Outpatient electiveAuthorization required category

Emergency/InpatientAuthorization not required

1-888-564-5492Phone

AvailityOnline

1-800-540-2406Fax

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Authorization and Coverage Criteria

Authorization and coverage criteria

Authorization is required before services are rendered for the listed outpatient advanced imaging and cardiology procedures; approval authorizes specific CPT/HCPCS code(s) but does not guarantee payment.

ALL of the following

Advanced imaging
- Magnetic resonance imaging (MRI)
- Magnetic resonance angiograms (MRAs)
- Positron emission tomography (PET) scans
- Positron emission tomography-computed tomography (PET-CT)
- Computerized tomography (CT) scans
- Computed tomography angiography (CTA) scans
- Nuclear medicine
Cardiology services
- Myocardial perfusion imaging (SPECT and PET)
- Stress echocardiography
- Echocardiography: transthoracic and transesophageal
- Diagnostic heart catheterization
- Nuclear cardiac imaging

Provider must obtain and confirm authorization prior to performing the service and verify member eligibility; authorization from eviCore does not guarantee claim payment.

Authorization number will be faxed to the provider upon approval; verification may be obtained via the eviCore website or by calling 1-888-564-5492.

Exceptions (no prior authorization required): No authorization is required for imaging/services provided in the emergency department, during an inpatient admission, or while the member is in observation status.

CPT / HCPCS Reference

CPT/HCPCS referencemixed

Comprehensive CPT and HCPCS code lists are maintained on the eviCore implementation website (evicore.com/healthplan/highmark).

Provider Responsibilities and Submission

Prior Authorization

Prior Authorization Required

All outpatient, non-emergent, elective procedures require prior authorization before services are rendered. This includes (but is not limited to) advanced imaging (MRI, MRA, PET, PET‑CT, CT, CTA, nuclear medicine) and cardiology services (myocardial perfusion imaging SPECT/PET, stress echocardiography, transthoracic and transesophageal echocardiography, diagnostic heart catheterization, nuclear cardiac imaging).

Prior authorization must be obtained prior to scheduling outpatient, non-emergent, elective procedures.
Authorization is required for the specific CPT/HCPCS code(s) for the requested procedure.

Note

Authorization Exceptions

Authorization is not required for emergency department services, inpatient services, or observation stay services.

Do not submit prior authorization requests for services rendered in the ED, during an inpatient admission, or during an observation stay.

Key Definitions

Urgent care definition — NCQA HUM8

DefinitionAny request for medical care or treatment where applying standard non-urgent timeframes could: (1) seriously jeopardize the member's life or health or the member's ability to regain maximum function, or (2) in the opinion of a practitioner familiar with the member, subject the member to severe unmanaged pain without the requested care (per NCQA HUM8).

When to use urgent pathwayWhen application of non-urgent determination time periods could result in serious jeopardy to life/health, loss of ability to regain maximum function, or severe unmanageable pain as judged by a prudent layperson or treating practitioner.

Submission methods for urgent requestsProviders must call eviCore at 1-888-564-5492 or submit via Availity; if submitted via Availity, all supporting clinical documentation must be uploaded at case initiation.

Standard referenced guidanceNational Committee for Quality Assurance (NCQA) HUM8 definition is used to determine urgent care status.

Documentation Required

How to Submit Requests

Providers may submit authorization requests via the Availity web portal, by phone, or by fax. For urgent outpatient requests, call 1-888-564-5492 or submit via Availity and upload all supporting clinical documentation at case initiation. The Availity portal allows case initiation, status checks, guideline review, and viewing authorizations or eligibility. Phone support is available at 1-888-564-5492 (7 a.m.–7 p.m. EST, M–F); leave a message after hours for next-business-day return. Fax requests may be sent to 1-800-540-2406 (note: fax is only an option for Medicare Advantage in West Virginia).

Availity (recommended): initiate case, upload clinical documentation, check status, and view authorizations/eligibility.
Phone: 1-888-564-5492 — have all pertinent clinical information ready. Hours: 7 a.m.–7 p.m. EST, Monday–Friday.
Fax: 1-800-540-2406 — use condition-specific forms from evicore.com (West Virginia Medicare Advantage only).
For portal assistance: portal.support@evicore.com or 1-800-646-0418, option 2.

Documentation Required

Post-Approval Responsibilities

Upon approval, an authorization number will be faxed to the provider and eviCore will approve the CPT or HCPCS code(s) for the requested procedure. It is the provider's or facility's responsibility to confirm prior authorization has been requested and approved prior to performing services. Verification can be obtained via the eviCore website, Availity, or by calling 1-888-564-5492. Authorization does not guarantee payment — the service must be covered by the health plan and the member must be eligible at the time of service. Claims for unauthorized procedures are subject to denial and the member must be held harmless.

An authorization number will be issued upon approval and the approved procedure codes will be specified.
Providers must confirm authorization prior to rendering services (check web portal, Availity, or call 1-888-564-5492).
Authorization is not a guarantee of claim payment; verify member eligibility and plan coverage prior to service.

Denial Risk

Denial and Appeal Process

If an authorization is denied, eviCore will notify the provider and member in writing and provide the rationale and appeal options within one working day of the decision. Providers may request a peer-to-peer review with an eviCore medical director (available for Commercial members) to discuss clinical information that may satisfy medical necessity criteria. For claim denials, follow the health plan's formal appeal process.

Written denial notice with rationale and appeal options will be issued within one working day.
Peer-to-peer consultations with an eviCore medical director are available for clinical discussion (Commercial members).
Claim denial reconsiderations must follow the payer's appeal process; clinical discussions via peer-to-peer are not substitutes for formal appeals.