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Anthem FAQ

1. Who is CareCore National?
CareCore National is a company that provides Utilization Management services for Health Plans or employer groups. CareCore National‘s mission is to provide Outpatient Diagnostic Imaging Service programs that improve quality and appropriateness of service.

2. What is the relationship between the Trust and CareCore National?
For its non-Medicare members in certain locations, the Trust has contracted with CareCore National to manage outpatient radiology services. Through this partnership, CareCore and the Trust will work together to strategically identify opportunities to enhance quality and improve utilization through seamless solutions that integrate all aspects of patient centered care. All participating providers are required to comply with the diagnostic imaging program, administered by CareCore National.

3. Which Anthem group members are impacted?

Group Name Plan Name Alpha Prefix Group Number
URMBT General Motors (non-Medicare) TCN UGD 71436
URMBT Chrysler (non-Medicare) TCN UCK 71400
URMBT Ford (non-Medicare) TCN UFK 71435

4. Will new ID cards be issued to the appropriate members?
Yes.

5. What procedures will require prior authorizations?
Magnetic Resonance Image (MRI)
Magnetic Resonance Angiography (MRA)
Computerized Axial Tomography (CT)
Positron-Emission Tomography (PET)
Nuclear Medicine, Nuclear Cardiology

The Provider Resources Page on the CareCore National website also provides detailed information on imaging exams.

6. What medical providers will be affected by this agreement?
All freestanding diagnostic facilities, outpatient hospital settings, and ambulatory surgery centers as well as any physician‘s office that provides MRI/MRA, CT, PET, Nuclear Medicine/Nuclear Cardiology services.

An approved authorization is required prior to rendering the above mentioned services. Claims submitted without the approved authorization may be denied for payment.

7. Do imaging services provided in an inpatient setting at a hospital or emergency room setting require a prior authorization from CareCore?
No, imaging studies ordered through an emergency room treatment visit, while in an observation unit or during an inpatient stay, do not require a prior authorization from CareCore National.

8. How can a referring provider indicate that an imaging study is clinically urgent?
The Provider should notify the CareCore National agent that the test is clinically "URGENT" and demonstrate the clinical urgency by including the appropriate clinical documentation.

9. How do I obtain a Prior Authorization from CareCore National?
Providers may initiate a prior authorization request through CareCore National‘s website, www.carecorenational.com, or by calling CareCore directly at 1-888-835-2042.

CareCore recommends initiating precertification by calling CareCore or submitting the request through the CareCore website. During the clinical review process, providers may be asked to fax additional medical history to CareCore. The fax number for submitting the additional clinical information is 1-800-540-2406.

10. What are CareCore National‘s hours and days of operation?
CareCore National is available from 7:00 a.m. to 7:00 p.m. local time, Monday through Friday.

Note: CareCore National is closed on New Year‘s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and the Friday following, and Christmas Day.

11. What is the process providers will follow if the patient requires a prior authorization after hours or on a Saturday?
If the test is not medically urgent, a physician with office hours later than CareCore National‘s call center may send a request via the fax or the through CareCore‘s website. CareCore National will process the request on the next business day. If the test is medically urgent and must be performed outside of CareCore‘s business hours, the physician may send the patient for the test and submit the authorization request (with supporting clinical documentation) within two business days. The request will be reviewed against medical necessity criteria and an approval will be issued as long as the request meets medical necessity criteria.

12. What information will be required to obtain a prior authorization?

  • Member‘s Plan Name
  • Patient‘s Name, Date of Birth, and the Member ID Number assigned by Anthem
  • Ordering Physician‘s Name, Provider‘s Health Plan ID Number, Address, Telephone and Fax Numbers
  • Requested Test(s) (CPT Code or Description)
  • Working Diagnosis
    • Signs and Symptoms
    • Results of Relevant Tests
    • Relevant Medications

If initiating the prior authorization by telephone, the caller should have the patient‘s medical records readily available. Please note that PET scans, certain CT Scans and Breast MRI‘s, may require clinical notes to be faxed to CareCore National.

13. How long will the prior authorization process take?
Approximately 70% of all requests are resolved on first contact. If a prior authorization is initiated online and the request meets criteria, the test will be approved immediately. A time stamped approval will be available for printing.

14. Does obtaining a prior authorization number guarantee payment?
The authorization number is not a guarantee of payment. Claims submitted for these services will also be subject to the following:

  • Member eligibility at the time services were provided
  • Benefit limitations and/or exclusions

15. Is a separate authorization needed for each CPT code?
Yes.

16. What will happen if the referring provider‘s office does not know the specific test code (CPT) that needs to be ordered?
CareCore National representatives will assist the physician‘s office in identifying the appropriate test based on presented clinical information and the Physicians‘ Current Procedural Terminology (CPT) code.

17. How long will the authorization approval be valid?
Prior Authorizations are valid for 30 calendar days from the date of the approval.

18. If a prior authorization number is valid for 30 days and a patient comes back within that time for follow up and needs another imaging study, will a new authorization number be required?
Yes.

19. Does the authorization number need to be included on the claim form when submitting an insurance claim for payment?
Yes, but only the Authorization Number for the Primary Procedure Code needs to be submitted on the claim.

20. What is the format of