Medical Policy Update (Feb. 2025)
Posted on February 7, 2025
Please read the following update related to various Health New England programs and changes that may have an impact on your patients and/or your practice.
If you have any questions about the information in this notice, please contact Health New England Provider Experience at (800) 842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m.
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Medicaid | Attention: Health New England, Inc. Network providers serving Medicaid Members
Each year, MassHealth requires all ACOs to submit paid claims for use in financial settlements and pricing of ACO capitation rates for the ensuing years. MassHealth has notified Health New England of the deadline for capture and final submission of paid Rate Year 2024 (RY 2024) service dates (1/1/2024 – 12/31/2024). For RY24, only claims processed and paid on or before 7/31/2025 will be considered by MassHealth. In keeping with the deadline, we would like to remind you of the Health New England Timely Filing Policy. The Timely Filing Policy requires that all claims must be submitted within ninety (90) days of the latter of the date of service or discharge. To comply with the MassHealth deadline and allow Health New England time to process and pay claims, we recommend submitting and resolving all concerns with Health New England claim payments as soon as possible upon your claim submission. Claims submitted late and not paid by 7/31/25 are subject to denial. |
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EviCore Radiology Migration
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Effective 3/1/25: Introducing the CareCore National portal platform.
Effective March 1, 2025, the management of Health New England radiology and cardiology prior authorizations through EviCore will transition from the MedSolutions portal platform to the CareCore National portal platform. While this change will have minimal impact on providers, the steps to submit authorizations through the portal will slightly change. That’s why we’d like to invite you to attend one of our upcoming virtual orientation sessions. Join us for a free virtual training session:
Health New England Migration Provider Orientation What: A 30-60 minute informational session and demonstration of how to submit prior authorization requests through the new portal platform Who: Designed specifically for provider office staff When: Various Eastern Time options in December Where: Virtual via WebEx Register today
Once you’ve registered, you will receive a confirmation email. Please keep the email so you have the WebEx link, meeting number, password, and call-in number for the session you will be attending. We recommend that you add the session to your calendar so you receive meeting reminders. For inquiries regarding the EviCore web portal, email the Web Support team at portal.support@EviCore.com, or call (800) 646-0418 (Option 2). For any Client or Provider inquiries not associated with this training, email ClientServices@EviCore.com or call (800) 646-0418 (Option 4). |
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EviCore Radiology
Frequently Asked Questions |
Who is EviCore healthcare?
EviCore healthcare (EviCore) is an independent specialty medical benefits management company that provides utilization management services for Health New England. Which members will EviCore manage for the radiology program? EviCore will manage prior authorization for Medicaid, Medicare and Commercial members. What is EviCore radiology program? EviCore’s radiology program consists of Prior Authorization Medical Necessity Determinations for advanced radiological services and Nuclear Cardiac codes. Our solution is designed around each client’s individual needs. This is accomplished by utilizing our unique clinical expertise with a staff of 300+ medical directors covering 51 different specialties and 800 licensed nurses with advanced training in various specialties. Additionally, we employ industry-leading clinical guidelines, including pediatric-specific imaging guidelines that incorporate all applicable criteria from medical specialty societies. Which radiology/cardiac services require prior authorization for Health New England Plans? CPT code list can be found on the resources page: Health New England Provider Resources | EviCore by Evernorth Radiology
Who needs to request prior authorization through EviCore? All physicians who request/order radiology services are required to obtain a prior authorization for services prior to the service being rendered in an office or outpatient setting. How do I request a prior authorization through EviCore? Providers and/or staff can request prior authorization in one of the following ways: Web Portal The EviCore portal is the quickest, most efficient way to request prior authorization and is available 24/7. Providers can request authorization by visiting www.evicore.com. Effective 3/1/25, prior authorization for Health New England’s radiology/nuclear cardiac program will be submitted on the CareCore National portal platform. Call Center EviCore’s call center is open from 7 a.m. to 7 p.m. local time. Providers and/or staff can request prior authorization and make revisions to existing cases by calling (866) 668-9659. Effective 3/1/25, this is a new phone number for Health New England prior authorization requests. Fax Providers and/or staff can fax prior authorization requests to (800) 540-2460 after completing the clinical worksheets found on EviCore’s website at www.evicore.com/provider/online-forms. Effective 3/1/25, this is a new fax number for Health New England prior authorization requests. Do radiology/nuclear cardiac services performed in an inpatient setting at a hospital or emergency room setting require prior authorization? No, these studies performed in an emergency room, while in an observation unit, or during an inpatient stay do not require prior authorization. How do I check an existing prior authorization request for a member? Our web portal provides 24/7 access to check the status of existing authorizations. To check the status of your authorization request, please visit www.evicore.com and sign in with your login credentials. Effective 3/1/25, prior authorization for Health New England will be submitted on the CareCore National portal platform.
What information is required when requesting prior authorization? When requesting prior authorization, please ensure the appropriate information is readily available: Member
Ordering Provider
Rendering (Performing) Provider
Clinical(s)
Note: EviCore suggests utilizing the clinical worksheets when requesting authorization for radiology services. How long is the authorization valid? Authorizations are valid for 30 calendar days. If the service is not performed within 30 calendar days from the issuance of the authorization, please contact EviCore. What is the most effective way to get authorization for urgent requests? Urgent requests are defined as a condition that is a risk to the patient’s health, ability to regain maximum function, and/or the patient is experiencing severe pain that requires a medically urgent procedure. Urgent requests may be initiated on our web portal at evicore.com or by contacting our contact center at (866) 668-9659. Urgent requests will be processed within 24 hours for Medicaid and 72 hours for Medicare and Commercial from the receipt of complete clinical information. Note: Please select urgent for those cases that truly are urgent and not simply for a “quicker” review. Also note that if a request is selected as urgent but does not meet guidelines to be considered urgent, the case may be reassigned as a routine case. How do I check the eligibility and benefits of a member? Member eligibility and benefits should be verified before requesting prior authorization through EviCore. Where can I access EviCore’s clinical worksheets and guidelines? EviCore’s clinical worksheets and guidelines are available online 24/7 and can be found by visiting one of the following links: Clinical Worksheets www.evicore.com/provider/online-forms Clinical Guidelines www.evicore.com/provider/clinical-guidelines After I submit my request when and how will I receive the determination? After all clinical info is received, for normal (non-urgent) requests a decision is made within 2 business days. For urgent requests, a decision is made within 72 hours (Medicare/Medicaid) and 72 hours (commercial). The provider will be notified by e-notification or fax. What are my options if I receive an adverse determination? The referring and rendering provider will receive a denial letter that contains the reason for denial as well as reconsideration and appeal rights process. Note: The referring provider may request a Clinical Consultation within two (2) business days with an EviCore Medical Director to review the decision. For Medicare members, the P2P will be consultative as the denial cannot be overturned. Does EviCore review cases retrospectively if no authorization was obtained? Retrospective requests must be initiated by phone within two (2) business days following the date of service. Please have all clinical information relevant to your request available when you contact EviCore healthcare. How do I make a revision to an authorization that has been performed? How do I make a revision to authorization that has not been performed? The requesting provider or member should contact EviCore with any change to the authorization, whether the procedure has already been performed or not. It is very important to update EviCore of any changes to the authorization in order for claims to be correctly processed for the facility that receives the member. What information about the prior authorization will be visible on the EviCore website? The authorization status function on the website will provide the following information:
How do I determine if a provider is in network? Participation status can be verified by contacting the HNE Provider Line (800) 842-4464 or Customer Service (800) 310-2835. Providers may also contact EviCore at (866) 668-9659. EviCore receives a provider file from Health New England with all independently contracted participating and non-participating providers. Where do I submit my claims? All claims will continue to be filed directly to Health New England. Where do I submit questions or concerns regarding this program? For program related questions or concerns, please email: clientservices@evicore.com Common Items to Send to Client Services:
Who do I contact for online support/questions? Web portal inquiries can be emailed to portal.support@evicore.com or call (800) 646-0418 (Option 2). What are the benefits of using EviCore’s Web Portal? Our web portal provides 24/7 access to submit or check on the status of your request. The portal also offers additional benefits for your convenience:
What information about the prior authorization will be visible on the EviCore website? The authorization status function on the website will provide the following information:
Where can I find additional educational materials? For more information and reference documents, please visit our resource page at: Health New England Provider Resources | EviCore by Evernorth |
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