Cardiology services, procedures and Authorization

1 What is the Cardiology Pre-Certification Program?

AA TThe Cardiology Pre-Certification Program is required for UnitedHealthcare Neighborhood Health Partnership participating providers, facilities and other health care professionals for certain inpatient, outpatient and officebased cardiac procedures prior to performance for UnitedHealthcare Neighborhood Health Partnership Commercial members. Neighborhood Health Partnership Commercial members can be identified by a reference to myNHP.com on the back of their healthcare identification (ID) card.

Pre-Certification is NOT required for services that take place in an emergency room or urgent care center. For a complete list of services that require pre-certification, please go to myNHP.com > Providers and scroll down to eviCore Pre-Certifications.

If you do not follow the Cardiology Pre-Certification Program protocol, administrative claim denials may result.

Providers cannot balance bill members for claims that are administratively denied.



2 How can providers obtain and verify a precertification number?

AA To request or verify a pre-certification number:

• Online: carecorenational.com

• Phone: 866-889-8054 from 7 a.m. to 7 p.m., local time, Monday - Friday



3 What cardiac procedures will require precertification?

AA Pre-certification is required for the following CPT codes:

Diagnostic Catheterization

• CPT codes: 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461


Electrophysiology Implants

• Pacemaker Implant CPT codes: 33206, 33207, 33208,  33212, 33213, 33214, 33227, 33228

• CRT (Cardiac Resynchronization Therapy) CPT device

codes: 33221, 33224, 33229, 33231, 33264, CPT Lead

Code 33225

• Defibrillator (AICD) Implant CPT codes: 33230, 33240,  33249, 33262, 33263


Echocardiogram

• CPT codes: 93303, 93304, 93306, 93307, 93308


Stress Echo

• CPT codes: 93350, 93351



4 In what places of service is a cardiac precertification NOT required?

AA Pre-certification is not required for cardiac services rendered in certain settings including, but not limited to, emergency rooms, urgent care centers, and inpatient settings (except for electrophysiology implants).

Pre-certification is required for each of the following procedures in the place of service identified:

Cardiac Procedure               Outpatient              Office                   Inpatient

Diagnostic
Catheterization                       Required                 Required               Not Required

Electrophysiology
Implants                                  Required                  Required               Required

Echocardiogram                     Required                   Required               Not Required

Stress Echo                            Required                   Required               Not Required


5 When is pre-certification required for CPT code 33225?

AA Pre-certification for the insertion of a pacing electrode (CPT code 33225) is required when obtaining pre-certification for a Cardiac Resynchronization Therapy (CRT) procedure.




6 Is pre-certification required for temporary pacemaker devices?

AA No. Pre-certification is not required for temporary pacemaker devices. Additionally, cardiac services that take place in an emergency room or urgent care center do not require pre-certification.



7 Is pre-certification required for pediatric cardiac catheterization cases?

AA No. The specific pediatric cardiac catheterization codes, CPT codes 93430, 93431, 93432 and 93433 are NOT in scope for these pre-certification requirements. However, if CPT codes requiring pre-certification are billed on a pediatric patient,  pre-certification will be required.



8 Is pre-certification required for electrophysiology implants rendered to pediatric  patients?

AA Yes. Electrophysiology implants rendered to pediatric patients do require pre-certification. The evidence-based clinical guidelines include pediatric indications. The rendering physician will follow the precertification process.


9 Why do some echocardiogram pre-certification requests get approved without providing clinical information and some require clinical information?

AA For echocardiograms, the Cardiology Pre-Certification Program focus is to determine the medical necessity for outpatient, non-emergent procedure requests for members with documentation of a prior echocardiogram. Members without a history of an echocardiogram performed within two years of the start of the program will be given a precertification number for the procedure without clinical review. If there is an echocardiogram procedure on file that was performed on the member within two years of the start of the program, clinical information will be collected for the medical necessity review.



10 Is UnitedHealthcare Neighborhood Health Partnership using a vendor to administer
this program?

A Yes. eviCore healthcare’s cardiology division will administerthe Cardiology Pre-Certification Program on behalf of UnitedHealthcare Neighborhood Health Partnership. We have taken special steps to ensure that the evidence-based clinical criteria we are using are current with best practices. We seek guidance from our external Cardiac Scientific Advisory Board, which is comprised of leading clinical and academic board-certified cardiologists, in reviewing  clinical criteria.


 11 What information may be required to obtain a pre-certification?

AA Information that may be requested before a pre-certification is considered include:

• Member’s plan name, member name, date of birth, telephone and address, member identification (ID) and
group number

• Ordering provider’s name, NPI, tax ID number, address, telephone and fax number

• Rendering provider’s name and address (if different than the ordering provider)

• The cardiac procedure(s) being requested, with the CPT code(s)

• The working diagnosis with the appropriate ICD code(s)

• The member’s clinical condition, which may include any  symptoms, listed in detail, with severity and duration; treatments that have been received, including dosage and duration for drugs; and dates for other therapies.

• Any other information that the provider believes will help in evaluating whether the service ordered meets current evidence-based clinical guidelines, including but not limited to, prior diagnostic tests and consultation reports. If the rendering provider is different from the ordering provider, the pre-certification number should be obtained and communicated by the ordering provider to the rendering provider.

12 Who will be reviewing pre-certification requests?

AA Board-certified cardiologists will perform the medical review for pre-certification requests. Ordering or rendering providers may request a clinical discussion with the reviewing cardiologist. To initiate a physician-to-physician discussion, call 866-889-8054, then:

• select prompt #3 and provide the 10-digit case number.

• If there is no case number or it is invalid, press *.


13 How long is a pre-certification number valid?

AA The pre-certification is valid for 45 days. UnitedHealthcare Neighborhood Health Partnership will use the date that the pre-certification number was issued as the starting point for the 45-day period in which the cardiac procedure must be completed. If the procedure is not completed within 45 days, a new pre-certification number must be obtained.