Unit 5: Outpatient Radiology and Laboratory
Highmark partners with eviCore healthcare (eviCore) for Highmark’s Advanced Imaging and Cardiology Services Program. This program incorporates a comprehensive, evidence-based clinical review, including predictive intelligence, clinical decision support, and peer-to-peer discussions.
Advanced Imaging Component
The following outpatient, non-emergent, elective advanced imaging procedures require authorization under the program:
- Computerized tomography (CT)
- Computerized tomography angiography (CTA)
- Magnetic resonance angiogram (MRA)
- Magnetic resonance imaging (MRI)
- Nuclear medicine
- Positron emission tomography (PET)
- Positron emission tomography-computed tomography (PET-CT)
Cardiology Services Component
The following outpatient, non-emergent, elective cardiology services require authorization under the program:
- Cardiac CT and MRI
- Diagnostic heart catheterization
- Myocardial perfusion imaging (single-photon emission computerized tomography [SPECT] and PET)
- Nuclear cardiac imaging
- Stress echocardiogram
- Transesophageal echocardiogram
- Transthoracic echocardiogram
List of Procedure Codes Requiring Authorization
The list of all procedure codes that require prior authorization under the Advanced Imaging and Cardiology Services Program is available on Highmark’s Provider Resource Center. On the Provider Resource Center, select Policies & Programs and look under Care Management.
The list is also available on eviCore’s website.
Authorization Not Required
eviCore does not manage prior authorization for advanced imaging or cardiology services that are performed during an inpatient stay, in an emergency room setting, or during an observation stay.
Members Impacted
eviCore manages the prior authorization process for advanced imaging and cardiology services for the following Highmark members:
- Fully insured commercial
- Medicare Advantage (in Pennsylvania and West Virginia)
- Affordable Care Act (ACA)
- Children’s Health Insurance Program (CHIP) in Pennsylvania
- Select self-insured (Administrative Services Only) groups
Since some employer groups may choose to opt out of the program, please be sure to always verify a member’s eligibility and benefits via Availity® to confirm whether the member’s coverage requires authorization.
Note: The Federal Employee Program (FEP) is excluded from this program.
Highmark Medical Policy and eviCore Clinical Guidelines
Highmark Medical Policy applies to services under the program. You can quickly access Highmark Medical Policy by clicking on MEDICAL POLICY SEARCH on the Quicklinks bar at the top of the Provider Resource Center.
You can access eviCore’s clinical guidelines at evicore.com/resources/healthplan/highmark. Scroll down to the eviCore Evidenced-Based Clinical Guidelines section on the right, click ACCESS GUIDELINES and then select Radiology & Cardiology.
Responsibility for Requests
It is the ordering provider’s responsibility to request prior authorization from eviCore under the Advanced Imaging and Cardiology Services Program.
Methods for Requesting Prior Authorizations
AVAILITY: Prior authorization requests for the program can be submitted to eviCore electronically via Availity, the preferred method for submitting requests.
Telephone: eviCore can accept requests by phone at 888-564-5492 from 7a.m. to 7p.m. EST, Monday through Friday. Outside of these normal business hours, you can leave a message for a return call the next business day.
Fax: To fax your request to eviCore, first obtain the appropriate condition-specific form from the eviCore website at eviCore.com. From RESOURCES on the menu bar, select Providers, and then Online Forms & Resources. Complete the form and fax it to 800-540-2406. When the authorization review is completed, eviCore will respond by fax with the decision.
Prior to submitting your request, please be sure to have all pertinent information at hand, including:
- Patient’s name, address, and current Member ID
- Diagnosis and procedure codes
- Office notes related to the current diagnosis
- Recent clinical information, including imaging studies and prior test results related to the diagnosis
Urgent Care Requests
An urgent care request is any request for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could result in the following circumstances:
- Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or
- In the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.
When a service is required due to a medically urgent condition, the ordering provider can request authorization by calling eviCore at 888-564-5492.
An urgent request can also be submitted online via Availity by selecting No on the urgency indicator screen in the submission process. However, please note that clinical documentation must be uploaded for urgent requests. You are able to upload up to five Word or PDF documents. Your case will only be considered urgent if there is a successful upload.
eviCore will make a good faith effort to render a decision for an urgent request within 24 hours and not to exceed 72 hours of receipt of all necessary information.
Approval Notification
Once the clinical pathway questions are answered and you have submitted the case, an approval is issued if the answers you have provided have met the clinical criteria. The approval page can be printed for the member’s file.
An authorization number will be assigned. All authorization numbers will begin with the letter “A” followed by nine digits. The authorization is valid for 60 days.
Here is an image that illustrates the approval page:
Medical Review Required
If additional information is required for medical review, you will have the option to upload documentation, enter information into the text field, or contact eviCore by phone. REMINDER: For urgent care requests, documentation must be uploaded.
Continue to the next screen to upload documents. You can upload up to five documents (maximum size 5MB; .doc, .docx, .pdf extensions only).
Authorization requests are reviewed and processed within two business days of eviCore’s receipt of all requested information. Requests are first reviewed by a nurse reviewer who can approve a request if it is determined that criteria is met. If the nurse reviewer is not able to make a determination, the case is reviewed by an eviCore Medical Director. Only an eviCore Medical Director can deny a request.
eviCore will notify the ordering provider of the decision via fax. A determination letter is mailed to the member.
If a request is approved, an authorization number is assigned. An authorization number will begin with the letter “A” followed by nine digits. The authorization is valid for 60 days.
Reconsiderations and Peer-to-Peer
Reconsiderations and peer-to-peer discussions will be available for commercial members only.
For Medicare Advantage members in Pennsylvania and West Virginia, consultations will be made available prior to a decision if requested. Once an authorization request has been denied, the decision cannot be overturned.
Providers Rendering Services
To avoid any unnecessary delay in payment, those providers rendering the specific advanced imaging or cardiology service should verify that the necessary authorization has been obtained prior to performing the service. Failure to do so may result in non-payment of your claim, and you may not seek reimbursement from the member.
Claims Adjudication
Under the terms of the agreement between Highmark and eviCore, Highmark will oversee the eviCore program and will continue to be responsible for claims adjudication. All claim inquiries should be directed to Highmark.
Retrospective Reviews
Retrospective requests must be submitted by phone or fax within 730 business days following the date of service. Requests submitted after 730 business days will be denied. All retrospective requests are reviewed for medical necessity with determinations made within 30 calendar days.
Note: Retrospective requests for dates of service prior to January 1, 2019, must be submitted to National Imaging Associates (NIA).
Medical Necessity Appeals
eviCore will process first-level provider appeals for commercial members. Highmark will process first-level provider appeals for all other members.
Requests for appeals for commercial members must be submitted to eviCore within the applicable time frames below:
- Delaware and West Virginia: 365 days of the initial determination
- Pennsylvania: 180 days of the initial determination
The procedure request and all clinical information provided will be reviewed by a physician other than the one who made the initial determination. A written notice of the appeal decision is mailed to the member and faxed to the provider.
Note: Appeals for services denied under the previous program for dates of service prior to January 1, 2019, must be submitted to NIA.
For More Information
Additional information about the program is available on Highmark’s Provider Resource Center. Select Policies & Programs and then look under Care Management.
eviCore provides a variety of resources at evicore.com/resources/healthplan/highmark. In addition to their clinical guidelines, you will find online forms, educational tools, helpful blogs, and more.
Providers must refer members to participating laboratory vendors when lab services are needed and are not performed in the provider’s office.
Prescription Necessary
PCPs and specialists need only give their members a prescription for the necessary lab tests and direct them to a network-participating lab.
Communication Between the PCP and Specialist
Specialty practitioners should communicate with a member’s PCP after a consultation visit so that laboratory services can be appropriately coordinated.
Pass-Through Billing Not Permitted
Pass-through billing occurs when ordering practitioners bill for clinical laboratory tests that were not performed in their offices. In Pennsylvania and Delaware, Highmark does not permit pass-through billing.
Practitioners should bill only for the component of the laboratory service they perform in their offices. Independent laboratories should bill for any clinical lab tests referred to them by practitioners.
Highmark will reimburse practitioners for drawing or handling when the specimen is sent to a laboratory other than the practitioner’s office lab and the clinical lab test is billed by the independent laboratory. However, if the clinical lab test is performed in the practitioner’s office and the practitioner bills for the test, an additional charge for drawing or handling will not be reimbursed. The handling or drawing of the specimen is considered part of the laboratory procedure.
Participating Independent Laboratory Lists
Availity is the preferred Highmark tool for inquiring about participating providers; however, if you are not Availity-enabled, please click the links below for a list of designated independent lab providers. Please select the appropriate region-specific link below:
Highmark has partnered with eviCore healthcare (“eviCore”) to ensure our members are receiving the most clinically appropriate genetic laboratory testing. eviCore has a team of 14 genetic counsellors and medical geneticists with national experience in genetic testing utilization management using evidence-based policies developed with trained genetic experts.
Under Highmark’s Laboratory Management Program, eviCore will perform medical necessity reviews for select molecular and genomic tests performed in an outpatient setting. In addition, all claims associated with molecular and genetic procedure codes will be reviewed for accuracy and medical necessity, based on eviCore’s policies.
Procedures Requiring Authorization
Prior authorization is required for certain outpatient, non-emergent molecular, and genomic testing, such as:
- Hereditary cancer screening
- Carrier screening
- Tumor marker/molecular profiling
- Hereditary cardiac disorders testing
- Cardiovascular disease and thrombosis risk variant testing
- Pharmacogenomics testing
- Neurologic disorders testing
- Mitochondrial disease testing
- Intellectual disability/developmental disorders testing
A complete list of impacted procedure codes is available at www.evicore.com/resources/healthplan/highmark. Once there, select SOLUTION RESOURCES, choose Laboratory Management, and then click CPT CODES.
Any services performed without prior authorization may be denied, and providers may not seek reimbursement from members.
Exclusions
Prior authorization is not required for the following:
- Inpatient genetic testing;
- General lab testing; or
- Genetic testing for CPT codes not included on eviCore’s prior authorization list.
Applicable Products
Highmark’s Laboratory Management Program applies to Highmark members with fully insured commercial, Affordable Care Act (ACA), and Medicare Advantage products.
The program is not applicable to traditional indemnity products, ASO (Administrative Services Only) accounts, National accounts, the Federal Employee Program (FEP), or BlueCard.
If you are uncertain whether a member’s benefits require authorization for genetic testing under the Laboratory Management Program, you can call eviCore at 888-564-5492 for confirmation of prior authorization requirements for the member.
Requesting Authorizations
Highmark recommends that ordering physicians secure authorizations and pass the authorization numbers to rendering facilities at the time of scheduling. Authorizations contain authorization numbers and one or more CPT codes specific to the services authorized. If the service requested is different from what is authorized, contact eviCore for review.
Availity-enabled providers should use Availity to submit authorization requests. If you attempt to submit a request and receive a message to call eviCore, authorization may not be required under the member’s benefit plan; the eviCore representative will assist in identifying the member and determining if authorization is needed.
If you are not Availity-enabled for authorization submission, you may use the eviCore Web Portal, available 24/7 at evicore.com, to request authorizations.
Authorizations are valid for 180 days. If the approved procedure is not completed by the Last Assigned Covered Day, a new request must be submitted.
Urgent Requests
If services are required in less than forty-eight (48) hours due to medically urgent conditions, please call eviCore at 888-564-5492 for authorization. Be sure to tell the representative that the authorization is for medically urgent care.
eviCore will make every effort to render a decision within one (1) business day of receipt of all necessary information.
Claim Submission & Reimbursement
Claims are submitted to Highmark following normal claim submission procedures, and you will receive reimbursement for eligible services from Highmark.
Claims Review Requirements
All claims associated with molecular and genomic procedure codes will be reviewed prior to payment for accuracy and medical necessity, based on eviCore’s policies, and matched against the authorization, if applicable. This review is not limited to those codes for which authorization is required. A list of codes subject to claims review is available at evicore.com.
For More Information
For complete program information, please see the Laboratory Management Program page on the Provider Resource Center – select Policues & Programs then look under Care Management.
Inpatient vs. Outpatient
When you submit claims to Highmark for diagnostic or therapeutic radiology services or diagnostic medical services provided to hospital inpatients or outpatients, you must report the place of service as inpatient hospital or outpatient hospital, as appropriate. In these cases, you will be reimbursed only the professional component of the service.
- Inpatient – a patient who is an inpatient of a facility, such as a hospital or skilled nursing facility, at the time the procedure is performed. When an inpatient is taken outside the hospital setting, such as to a physician’s office, and is then returned to the hospital, the physician must report services according to the patient’s status, in this case, inpatient. Therefore, you must report only “inpatient” as the place of service, rather than the place, such as “office” or “outpatient hospital,” where the service actually was performed.
- Outpatient – a patient, other than an inpatient, who is treated in a hospital, on hospital grounds, or in a hospital-owned or controlled satellite, when it has been determined that the satellite is an outpatient department of the hospital. This definition does not apply when a treating physician’s sole practice is located in a hospital or hospital-owned building, if the practice is not affiliated or controlled, in any way, by the hospital or a related entity; or, if the practice has been approved to be recognized as an office practice.
For example, if a mobile ultrasound, MRI, or CT unit locates on hospital grounds one day each week, all services provided to patients on that day must be reported with inpatient or outpatient, but not office, as the place of service.
Highmark offers optional benefit designs that include cost-sharing provisions specific to outpatient diagnostic services.
Services Affected
Cost sharing on outpatient diagnostic services will be applied to:
- Routine/preventive diagnostic services (with the exception of all mammograms and the annual routine Pap test), and
- Non-routine diagnostic services, including pre-admission testing.
Impacted Products
Products that may have a cost-sharing benefit design include Exclusive Provider Organization (EPO) and Preferred Provider Organization (PPO) plans, including Medicare Advantage PPO.
Note: Cost-sharing provisions will not be noted on Member ID cards. Please review member benefits accordingly through Availity® or by contacting Provider Services if you are not an Availity-enabled provider.
Five Categories of Outpatient Diagnostic Services
Advanced Imaging Services:
- Advanced Imaging Services – include, but are not limited to, computed tomography (CT), computed tomography angiography (CTA), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), positron emission tomography (PET scan), and positron emission tomography/computed tomography (PET/CT scan).
Basic Diagnostic Services:
- Standard Imaging Services – procedures such as skeletal X-rays, ultrasound, and fluoroscopy.
- Diagnostic Medical Services – procedures such as stress echocardiography, myocardial perfusion imaging (MPI), electrocardiograms (ECG), pulmonary studies, echocardiograms, electroencephalograms (EEG), regular treadmill stress tests, and audiology tests.
- Laboratory and Pathology Services – procedures such as non-routine Papanicolaou (Pap) smears, blood tests, urinalysis, biopsies, and cultures.
- Allergy Testing Services - allergy testing procedures such as percutaneous tests, intracutaneous tests, and patch tests.
How Coinsurance is Applied
If a member has coinsurance, it is applied to all line items identified as outpatient diagnostic services either on Advanced Imaging only or also on the four categories of Basic Diagnostic Services depending on the benefit design selected. The coinsurance amount (e.g., 80%) for the four categories of Basic Diagnostic Services is the same. Coinsurance for outpatient diagnostic services is applicable to the total component, technical component, and/or professional component only.
The member may be responsible for both a copayment and coinsurance when a service, such as an office visit or therapy service, and an outpatient diagnostic service are performed on the same date of service.
How Copayments are Applied
If a member has copayments on outpatient diagnostic services, they are applied per date of service and per type of diagnostic service. If services fall in more than one of the five diagnostic service categories (see above chart), multiple copayments can be applied. Please review the member’s benefit program to determine if a copayment is owed on multiple services.
Copayments may be applicable to only the advanced imaging services or also to all four categories of basic diagnostic services. The copayment amount for the advanced imaging services would usually be a higher amount (e.g., $100). The copayment amount for the four categories of basic diagnostic services is the same (e.g., $25 for each type of service).
Copayments are applied to the total component or technical component claims for outpatient diagnostic services. Copayments are not applied to professional component only claims (26 modifier).
Please Note: For Medicare Advantage products with outpatient diagnostic copayments, copayments are applied per date of service, per type of diagnostic service, and per provider.
Examples of Multiple Copayments and/or Coinsurance
- If a PPO member sees his cardiologist and receives an EKG during the visit, he would be responsible for two copayments: an office visit copayment and an outpatient diagnostic service copayment for the EKG (diagnostic medical service).
- If a PPO member receives an MRI (advanced imaging service), then has a spinal X-ray (standard imaging service) and lab work (laboratory/pathology service) on the same day – all as outpatient services – she would be responsible for three outpatient diagnostic copayments.
- If an EPO member sees his cardiologist and receives a regular treadmill stress test (basic diagnostic medical service) while there, he would pay an office visit copayment, and then would be responsible for any applicable coinsurance when the stress test claim is processed.
- If a Medicare Advantage member with outpatient diagnostic copayments sees her cardiologist and receives an EKG (basic diagnostic medical service) while there and on the same day goes to another physician and receives a regular treadmill stress test (also a basic diagnostic medical service), she would be responsible for two copayments, one for each provider.
Cost Sharing Exceptions
- All mammograms (routine and medically necessary) and the annual routine Pap tests are generally unaffected by the cost sharing benefit designs.
- Diagnostic services performed in conjunction with an emergency room visit would not be impacted in most cases.
- There may be situations where cost sharing may apply in the first two situations, especially for self-insured employer groups. Please be sure to review each service on a case-by-case basis.
Determining if Members have Cost-Sharing
More information on outpatient radiology and other diagnostic services cost sharing can be easily accessed through Availity by selecting the appropriate service type, or by contacting the Provider Service Center if you are not a Availity-enabled provider.
To verify outpatient diagnostic benefits in Availity, select Additional Benefit Notes from the Eligibility and Benefits detail page.
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
