Q: What is the HealthPlus Cardiology Prior Authorization Program?A: HealthPlus has contracted with CareCore National (CCN), an NCQA
and URAC accredited specialty benefits management company to ensure requests for
select outpatient diagnostic cardiology services meet evidence-based guidelines
supported by the American College of Cardiology, American Heart Association and
Heart Rhythm Society.
Q: What cardiology procedures are included in the Prior Authorization Program?A: The following procedures require Prior Authorization:
Q: Which HealthPlus products adhere to this program?A: Commercial HMO and PPO, Options, and Medicare Plus Advantage
HMO, when HealthPlus is secondary to other commercial insurances. Medicare Plus Advantage PPO are encouraged to obtain
a Pre Visit Coverage Decision.
County Health Plan and Medicare Supplemental lines of business are excluded
from the Cardiology Prior Authorization Program.
Q: Are there additional program exclusions?A: HealthPlus members under the age of 18 (at the time of the
service) are excluded from Prior Authorization.
Q: Who is responsible for prior authorization of the procedure?A: The ordering provider (PCP or cardiologist) should complete
the prior authorization, to ensure complete clinical information is provided.
Q: How do I prior authorize a procedure and how long will it take to receive
a response?A: You may prior authorize a procedure in 1 of 3 ways:
Note: Most prior authorization approvals will be immediate
for web and phone submissions. No prior authorization will take more than 2 business
days when complete clinical documentation is submitted.Q: What are CCN’s hours and days of operation?
A: 7 a.m. to 7 p.m. (Eastern Standard Time) Monday through Friday
Note: CCN observes the following holidays: New Year’s Day, Memorial
Day, Independence Day, Labor Day, Thanksgiving Day and the Friday following, and
Christmas Day.Q: What information must I provide during prior authorization?A: The following must be provided:
Note: For your convenience, criteria and modality worksheets
are available at carecorenational.com, under http://www.carecorenational.com/page/cardiology-tools-and-criteria.aspxQ: Can I speak with a CCN cardiologist if I have questions related to the outcome
of a prior authorization determination?A: Yes. The review team is staffed by cardiac trained nurses and
cardiologists. Upon request, a cardiologist can speak to you about your case and
Q: How can I initiate the prior authorization of a procedure, outside of CCN’s
normal business hours?A: A physician can perform a medically
urgent request outside of CCN’s normal business hours; however
the ordering provider must request authorization of the procedure within two (2)
business days. The ordering provider will need to submit the clinical indications
for the test, including the reason it was deemed medically urgent.
Q: How do I indicate a service is medically urgent?A: Upon calling CCN, notify the phone agent that the test is medically
“URGENT”. You will be required to provide clinical documentation, supporting medical
Q: Can the rendering provider change an authorized CPT code?A: Medical necessity review through CCN is required when CPT code
changes are made to an approved authorization. The CPT code change request can be
performed up to 2 business days after the procedure is performed by contacting CCN
with all supporting clinical documentation at 1-800-792-8744.
Q: How will the ordering provider or the rendering provider know that a prior
authorization request has been completed?A: Depending upon the method used for submitting the prior authorization
request, the response may be immediate; however a prior authorization status can
also be verified at carecorenational.com under “Authorization Lookup”. Information
Note: Providers who do not have web access can contact
CCN directly at 800-792-8744. Q: Will my patient receive notification of the prior authorization?A: Members will be notified by letter of all Prior Authorization
Q: What will happen if I do not prior authorize a required procedure?A: Failure to complete the prior authorization process will result
in non-payment of the technical (facility) and professional components of the claim.
Prior authorization (based on medical necessity) must be in place before rendering
to guarantee payment of services.
Q: How long will the approval be valid?A: The prior authorization approval is valid for 45 calendar days
from the date of the approval. After 45 days, if the test has not been performed,
or if the recommended test has changed, a new prior authorization approval is needed.
Q: If a prior authorization is valid for 45 days and a patient comes back within
that time for follow up and needs another test, will a new test prior authorization
be required?A: Yes. Prior Authorization approvals are procedure code-specific
and for one-time use.
Q: Is a prior authorization still required from HealthPlus for a member to see
a specialist performing the diagnostic test?A: Yes, all applicable referral requirements to obtain access to
a specialist are still in effect. A valid prior authorization does not mitigate
the need for a referral to the specialist.
Q: How do I bill for an urgent diagnostic cardiac catheterization, performed
in the observation setting (LOC 22)?A: Please include the modifier “ET”.
Q: Do add-on procedures require prior authorization?A: No. Add-on procedures (e.g. 93320) are reviewable under the
primary procedure when prior authorization for the primary procedure is in place.
Q: What if CCN doesn’t approve my test request?A: CCN is delegated to process all appeals, EXCEPT for Medicare
Advantage appeals. The ordering provider can contact CCN directly at 800-792-8744.
Medicare Advantage appeals are processed through HealthPlus. Contact HealthPlus
Customer Services at 800-332-9161 for assistance.
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