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INSURANCES THAT REQUIRE PRECERTIFICATION AND INSURANCE REFERRALS (PDF)

VIEWS: 79 PAGES: 4

									John R. Melnick, M.D.                                                                                    William Louie, M.D.
Mona Darwish, M.D.                                                                                       Keith S. Tobin, M.D.
Shelley E. Wertheim, M.D.                                                                                Andrew Kwai, M.D.
Caren Jahre, M.D.                                                                                        Gregory E. Wilde, M.D.
Kathy J. Tobin, M.D.                                                                                     Hilary Umans, M.D.
Karen B. Wagner, M.D.                                                                                    Stacy L. Jacobs, M.D.
Karen Fried, M.D.                                                                                        Steven Tuzinkiewicz, M.D.
Lori Goffner, M.D.                                                                                       Peter L. Glickman, M.D.
David L. Milbauer, M.D.                                                                                  Evan Morton, M.D.

                    61 East 77th Street, New York, NY 10075 (Between Park & Madison Avenues)
                        240 Madison Avenue, New York, NY 10016 (Between 37th & 38th Street)
  202 East 70th Street, New York, NY 10021 (Between 2nd & 3rd Avenues) • 161 Atlantic Avenue, Brooklyn, NY 11201
                    TEL: 212-772-3111 • FAX: 212-288-1637 • www.lenoxhillradiology.com

    INSURANCES THAT REQUIRE PRECERTIFICATION AND INSURANCE REFERRALS
                             (This is not a complete list of insurances in which we participate)

 Since insurance requirements frequently change, patients should call their carrier to insure coverage of all medical
 procedures. The following is a list of insurances known to require precertification for Radiology exams. Please give our
 Tax ID # (133425028) when verifying coverage or obtaining precertification as our listing (Doctor-Facility) may
 vary by insurance carrier.

 1199
 All members require prior approval for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans from CaretoCare
 (888-910-1199).
 1199 Homecare Benefit Fund/Fidelis
 Precertification required for PET-CT scans. Please call (888-343-3547).
 32BJ EMPIRE BCBS
 All members require precertification for MRI/MRA, CT/CTA and PET-CT scans from AIM (877-430-2288).
 AETNA
 Precertification requirements vary per plan. You must call Aetna Provider Services (888-632-3862, option 2) for
 guidelines. Precertification may be required for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CareCore
 National. Out-of-state plan precertification requirements may be different from New York-based plans, please contact Aetna.
 AFFINITY
 All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CareCore National
 [(866-242-5615); (www.carecorenational.com)].
 AMERIGROUP/CAREPLUS
 All members require precertification for MRI/MRA, CT/CTA and PET-CT scans via NIA (800-642-7565).
 AMERIHEALTH
 Members may require precertification for MRI/MRA, CT/CTA and PET-CT scans via American Imaging Management
 (800-275-2583).
 AMERIHEALTH ADMINISTRATORS
 Precertification requirements vary per plan. Please call the phone number on the member's card for precertification guidelines.
 AMIDACARE (formerly VIDACARE)
 Precertification required for MRI/MRA and PET-CT scans from Utilization Management (888-364-6061 option 1). All other
 exams require an in-network referral.
 ANTHEM/BlueCross BlueShield
 Precertification requirements vary per plan. Please call the phone number on the member's card for precertification guidelines.
 ATLANTIS HEALTH (www.atlantishp.com)
 All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans, Ultrasound-guided FNA/
 Biopsy procedures, Stereotactic Breast Biopsy and pregnancy-related US scans through Atlantis Medical Management
 (800-270-9072). Please call our Authorization/Referral Department (ext 2004) for the list of CPT-codes for Ultrasound-guided
 FNA/Biopsy and Stereotactic Breast Biopsy procedures. Please keep in mind that precertification requests may take up to 3
 business days once all clinical information has been submitted.
 BLUECROSS BLUESHIELD
 Precertification requirements vary per plan. Empire BC/BS plans may require precertification for MRI/MRA, CT/CTA,
 and PET-CT scans via AIM (877-430-2288) or Medical Management (800-982-8089). For out-of-state BCBS plans, please
 call the phone number on the member's card for precertification guidelines. If you do not have the member’s card but have
 the alpha-prefix ID, you can call the Blue line (800-676-2583, option 4) and your call will be forwarded to the health plan.
 CENTERCARE (www.centercare.org)- (MERGED WITH FIDELIS)
 Please call Fidelis (888-343-3547).
John R. Melnick, M.D.                                                                                   William Louie, M.D.
Mona Darwish, M.D.                                                                                      Keith S. Tobin, M.D.
Shelley E. Wertheim, M.D.                                                                               Andrew Kwai, M.D.
Caren Jahre, M.D.                                                                                       Gregory E. Wilde, M.D.
Kathy J. Tobin, M.D.                                                                                    Hilary Umans, M.D.
Karen B. Wagner, M.D.                                                                                   Stacy L. Jacobs, M.D.
Karen Fried, M.D.                                                                                       Steven Tuzinkiewicz, M.D.
Lori Goffner, M.D.                                                                                      Peter L. Glickman, M.D.
David L. Milbauer, M.D.                                                                                 Evan Morton, M.D.

                    61 East 77th Street, New York, NY 10075 (Between Park & Madison Avenues)
                        240 Madison Avenue, New York, NY 10016 (Between 37th & 38th Street)
  202 East 70th Street, New York, NY 10021 (Between 2nd & 3rd Avenues) • 161 Atlantic Avenue, Brooklyn, NY 11201
                    TEL: 212-772-3111 • FAX: 212-288-1637 • www.lenoxhillradiology.com
     INSURANCES THAT REQUIRE PRECERTIFICATION AND INSURANCE REFERRALS

 CIGNA (www.cigna.com)
 Precertification requirements vary per plan. Please call Cigna number on card for precertification guidelines. Cigna Open
 Access Plus, HMO and POS plans may require precertification for MRI/MRA, CT/CTA and PET-CT scans via American
 Imaging Management [(800-252-2021); https://www.providerportal.com]. For Cigna PPO, precertification is via Cigna's
 Medical Management (800-882-4462).
 ELDERPLAN
 All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CaretoCare
 (866-390-7526).
 EMPIRE GOVERNMENT PLAN (NYSHIP)
 All members require notification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via the Empire Plan Notification
 Line (888-333-9067).
 FIDELIS CARE (www.fideliscare.org)
 Precertification required for PET-CT scans and 4th or more OB Ultrasounds. Please call (888-343-3547).
 GEHA (www.geha.com)
 All members require precertification for MRI/MRA, CT/CTA, and PET-CT scans through MedSolutions (866- 879-8317).
 GHI PPO and HMO (www.ghi.com)
 Most members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CareCore National
 [(800-835-7064); (www.carecorenational.com)].
 GHI NETWORK ACCESS
 Precertification requirements vary per plan/group. Please call the phone number on the member’s card for precertification
 guidelines. Generally speaking, MRI/MRA, CT/CTA, PET-CT, Nuclear Medicine scans and Ultrasound-guided FNA/Biopsy
 and Stereotactic Breast Biopsy procedures will require precertification. Please call our Authorization/Referral Department
 (ext. 2004) for the list of CPT-codes for Ultrasound-guided FNA/Biopsy and Stereotactic Breast Biopsy procedures.
 GREAT WEST
 All members require precertification for MRI/MRA, CT/CTA and PET-CT scans via MedSolutions [(888-693-3295);
 (www.medsolutions.com)].
 HEALTHFIRST (All Plans)
 All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CareCore National
 [(877)773-2884; (www.carecorenational.com)].
 HEALTH PLUS (www.healthplus-ny.org)
 All members require precertification for MRI/MRA and PET-CT scans, please call (800-450-8753).
 HIP (www.hipusa.com)
 All HIP Fee-for-Service members in HMO, POS, Medicaid, Medicare, Child Health Plus, Family Health Plus benefit plans
 require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CareCore National [(866-417-2345);
 (www.carecorenational.com)]. Some plans may be capitated to a particular HIP Center in which case precertification or
 referrals must be obtained through the center. Some plans may require precertification via the Lenox Hill Healthcare Network
 (800-633-0695) or HIP Medical Management (888-447-2884). Electronic referrals are required for all HMO policies as well as
 some POS/PPO policies. Referrals are not required for routine mammography screening, HIP Access I and II plans and
 EPO/PPO members.
 HIP CMO
 For members whose PCPs are capitated to the CMO/Montefiore network, precertification will be required for MRI/MRA and
 PET-CT scans and notification will be required for CT/CTA and Nuclear Medicine scans, please call (877-447-6668).
 HIP HEALTHCARE PARTNERS (formerly Heritage)
 All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans. Please call (888-746-2200).
 All exams that do not require precertification will require referrals including x-ray, ultrasound and mammography exams.
John R. Melnick, M.D.                                                                                    William Louie, M.D.
Mona Darwish, M.D.                                                                                       Keith S. Tobin, M.D.
Shelley E. Wertheim, M.D.                                                                                Andrew Kwai, M.D.
Caren Jahre, M.D.                                                                                        Gregory E. Wilde, M.D.
Kathy J. Tobin, M.D.                                                                                     Hilary Umans, M.D.
Karen B. Wagner, M.D.                                                                                    Stacy L. Jacobs, M.D.
Karen Fried, M.D.                                                                                        Steven Tuzinkiewicz, M.D.
Lori Goffner, M.D.                                                                                       Peter L. Glickman, M.D.
David L. Milbauer, M.D.                                                                                  Evan Morton, M.D.

                    61 East 77th Street, New York, NY 10075 (Between Park & Madison Avenues)
                        240 Madison Avenue, New York, NY 10016 (Between 37th & 38th Street)
  202 East 70th Street, New York, NY 10021 (Between 2nd & 3rd Avenues) • 161 Atlantic Avenue, Brooklyn, NY 11201
                    TEL: 212-772-3111 • FAX: 212-288-1637 • www.lenoxhillradiology.com

    INSURANCES THAT REQUIRE PRECERTIFICATION AND INSURANCE REFERRALS

MEDICAID (www.emedny.org)
Please verify Medicaid eligibility to ensure member's coverage is not through a Managed Care plan via eMedNY or the
Medicaid Verification System through OMNI. All Fee-For- Service Medicaid members who are not enrolled in a Managed
Care plan, require prior approval for MRI/MRA, CT/CTA and PET-CT scans from RadConsult™ administered by HealthHelp
(888-209-4122). Medicaid members who've selected a Managed Care plan may require precertification from the respective
utilization management entities.
MERITAIN
Precertification requirements vary per plan. Please call the phone number on the member’s card for precertification guidelines.
METROPLUS
For the Medicaid plan, precertification is not required for out-patient radiology exams. For the Medicare plan, precertification
is required, please call (800-303-9629).
MULTIPLAN
Precertification requirements vary per plan. Please call the phone number on the member's card for precertification guidelines.
MVP
Certain MRI/MRA, CT/CTA, PET-CT scans require precertification. Please call the phone number on the member's card for
precertification guidelines.
NEIGHBORHOOD HEALTH PROVIDERS
Precertification is required for all MRI/MRA, CT (brain and pelvis only), PET-CT and Nuclear Medicine scans, please call
(800-765-3805). Effective 5/1/11, all MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans will require precertification,
please fax (800-338-4195) or submit via NHP web portal (www.getnhp.com).
OXFORD
All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans and 3rd or more OB
Ultrasounds via CareCore National [(877-773-2884); (www.carecorenational.com)]. Some plans may be capitated to CMO
network and will require precertification via CMO (800-876-7455). Please note that Doppler studies (Carotid and Extremity),
arthrograms and biopsy procedures require an electronic Oxford referral for all Oxford members except those with non-gated
policies.
PERFORMAX (www.myperformax.com)
All members require precertification for MRI/MRA, CT/CTA, PET-CT scans, please call (800-337-0506).
PHCS
Precertification requirements vary per plan. Please call the phone number on the member's card for precertification guidelines.
PHS/HEALTHNET
Advantage Platinum plan (PPO, HMO, POS) members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear
Medicine scans via CareCore National [(866- 898-6287); (www.carecorenational.com)]. Some plans may be capitated to the
CMO network and will require precertification via CMO (888-666-8326). Some out-of-state plans require precertification via
MedSolutions [(888-693-3211); (www.medsolutions.com)].
PRINCIPAL FINANCIAL GROUP
All members (except self-funded policies) require prior approval for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans
from NIA (888-899-7805).
UMR (by United Healthcare)
Precertification requirements vary per plan. Please call the phone number on the member’s card for precertification guidelines.
U.S. FAMILY HEALTH PLAN
All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans. Please call [(866-390-0933);
(www.medsolutions.com)].
UNICARE
Some members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans. Please call
(800-288-8630) to verify precertification requirements.
John R. Melnick, M.D.                                                                                       William Louie, M.D.
Mona Darwish, M.D.                                                                                          Keith S. Tobin, M.D.
Shelley E. Wertheim, M.D.                                                                                   Andrew Kwai, M.D.
Caren Jahre, M.D.                                                                                           Gregory E. Wilde, M.D.
Kathy J. Tobin, M.D.                                                                                        Hilary Umans, M.D.
Karen B. Wagner, M.D.                                                                                       Stacy L. Jacobs, M.D.
Karen Fried, M.D.                                                                                           Steven Tuzinkiewicz, M.D.
Lori Goffner, M.D.                                                                                          Peter L. Glickman, M.D.
David L. Milbauer, M.D.                                                                                     Evan Morton, M.D.

                    61 East 77th Street, New York, NY 10075 (Between Park & Madison Avenues)
                        240 Madison Avenue, New York, NY 10016 (Between 37th & 38th Street)
  202 East 70th Street, New York, NY 10021 (Between 2nd & 3rd Avenues) • 161 Atlantic Avenue, Brooklyn, NY 11201
                    TEL: 212-772-3111 • FAX: 212-288-1637 • www.lenoxhillradiology.com
     INSURANCES THAT REQUIRE PRECERTIFICATION AND INSURANCE REFERRALS
                               (This is not a complete list of insurances in which we participate)

 UNITED HEALTHCARE
 New York-based plans do not require precertification for outpatient diagnostic studies. If the referring doctor is from New
 Jersey, precertification is required via CareCore National [(800-818-8307); (www.carecorenational.com)].
 UNITED HEALTHCARE COMMUNITY PLAN (formerly Americhoice)
 All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CareCore National
 [(866-889-8054); (www.carecorenational.com)].
 UNITED HEALTHCARE: Medicare Solutions (AARP, SECURE HORIZONS, EVERCARE)
 All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CareCore National
 [(866-889-8054); (www.carecorenational.com)].
 VNS Choice Select
 Precertification required for MRI/MRA, CT/CTA, PET-CT, Nuclear Medicine scans from VNS Medical Management
 (866-791-2215). Please keep in mind that precertification requests may take up to 2 business days once all clinical
 information has been submitted.
 WELLCARE
 All members require precertification for MRI/MRA, CT/CTA, PET-CT and Nuclear Medicine scans via CareCore National
 [(888-333-8641); (www.carecorenational.com)].

 BILATERAL PROCEDURES
 Bilateral procedures usually require two separate approval numbers, unless if the insurance company usually approves
 multiple exams under one number. For CareCore National cases, any bilateral extremity (hips, knees, ankles, feet, shoulders,
 wrists, hands, elbows) being ordered by the doctor must have two separate approval numbers. CareCore National usually
 issues only one approval number for the MRI of bilateral hips if the approval for both hips is called in or obtained during the
 same phone call. However, obtaining one approval number for MRI of bilateral hips usually creates a claims issue - the claim
 for one of the MRI hip will be denied. We strongly advise you to call or create online approvals for each hip separately.

 OB ULTRASOUNDS
 OB Ultrasounds, in excess of 3 per pregnancy may require precertification. Please call the patient’s health plan for requirements.

 LIEN
 We will accept a Lien agreement on all open/active cases. To reach our Lien Department, please dial our main number,
 212-772-3111, extension 1432 to reach Raymond Medina.

 NO-FAULT
 All No-fault patients must bring accident/insurance information and attorney information. Please call our No-fault office to
 confirm insurance information. To reach our NF Department, please dial our main number, 212-772-3111, extension 1432
 to reach Raymond Medina.

 WORKERS COMPENSATION
 All Workers Compensation procedures must be verified before the exam is performed. Please be sure to have the patient’s
 workers compensation carrier information including the name, address, telephone number, claim number, and the adjuster’s
 name along with the workers compensation board case number. It is also necessary to provide the employer name and date
 of injury. Prior authorization may be required for MRI /MRA scans in some cases. Most workers compensation carriers now
 require radiological testing to be scheduled through their preferred individual networks. It is important that any scheduled tests
 must be for the specific established injury site. Any tests to be performed on a non-established injury site will need to first be
 approved by the WCB. This process can sometimes take up to 4 weeks. For additional information regarding radiology
 testing, the individual carrier should be contacted directly. To reach our WC Department, please dial our main number,
 212-772-3111, extension 1413 to reach Monica Kelly.

                                                                                                               LAST REVISED 04/11

								
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