Reminder - TPL bypass for High Tech Imaging (eviCore) Claims

This is a reminder that February 1 enhancements to NCTracks provided resolution to the issue of claims denying in error for lack of an eviCore prior authorization when retroactive changes have been made to a recipient's TPL (other primary insurance) record. A bypass was applied to the prior approval (PA) requirements for outpatient non-emergency high-tech imaging procedures. Claims should not deny for High Tech Imaging PA edit when retroactive changes occur to a recipient's Third Party Liability (TPL) file.

Scenarios applicable are when the claim line date of service indicates that during the date of service the recipient:

- Is enrolled in Insurance Type 00, 08, 10, 11, 18, 20 * or

- Is dual eligible or

- The other insurance has made a payment towards the service or

- The other insurer has indicated that the insurance payment has gone toward the patient's insurance deductible

This change is only applicable to the Division of Medical Assistance (DMA) health plans. Providers can resubmit past denied claims affected and provide time limit override documentation if applicable

Please refer to Prior Approval for Imaging Policy 1K-7 for the list of codes that require prior authorization for high tech imaging.

 

* Insurance Type Code Definitions:

00 MAJOR MEDICAL COVERAGE (ANY POLICY THAT HAS NO COMPLEMENTARY INSURANCE CODE 16 MUST REMAIN IN  THIS CODE AT CONVERSION (WHEN GO LIVE THIS CODE WILL NO LONGER BE VALID FOR NEW POLICY  ENTRIES)
08 BASIC MEDICARE SUPPLEMENT COVERAGE ONLY
10 MAJOR MEDICAL AND DENTAL COVERAGE (WHEN GO LIVE THIS CODE WILL NO LONGER BE VALID FOR  NEW  POLICY ENTRIES)
11 MAJOR MEDICAL AND LONG TERM CARE COVERAGE (WHEN GO LIVE THIS CODE WILL NO LONGER BE  VALID FOR  NEW POLICY ENTRIES)
18 MAJOR MEDICAL WITH PRESCRIPTION DRUG COVERAGE (TO BE USE IF RX CLAIMS GO TO SAME ADDRESS AS MAJOR MEDICAL CLAIMS
20 MAJOR MEDICAL WITHOUT PRESCRIPTION DRUG COVERAGE (TO BE USED WHEN THE POLICY DOES NOT  COVER RX DRUGS OR IF THE RX DRUG CLAIMS ARE PROCESSED BY A PBM)