Cardiology Imaging Program Provider Questions and Answers

Horizon BCBSBJ collaborates with eviCore healthcare (eviCore) to administer our Cardiology Imaging program. Through this program, eviCore uses evidence-based criteria to help ensure that the cardiac imaging studies provided to our members are appropriate based on patient medical and prior imaging history and that services meet the high quality standards recommended by organizations such as the American College of Cardiology, the American Heart Association and the Heart Rhythm Society.

This content was last revised on January 12, 2022 and may be subject to change.

Q1. How do I determine if a member participates in this program?
A1. To verify a member’s participation in this program, please visit eviCore.com, 24 hours a day, seven days a week or call eviCore at 1-866-496-6200, weekdays, between 7 a.m. and 7 p.m., Eastern Time (ET), and Saturday and Sunday, between 9 a.m. and 5 p.m., ET.

Q2. Which services require a PA/MND?
A2. The following services require the ordering physician to request a PA/MND:

• Echo Stress Test
• Diagnostic Left Heart Catheterization
• Echocardiogram

Q3. Does an initial echocardiogram require a PA/MND?
A3. Yes, under this program, a member’s initial echocardiogram requires prior notification, not prior approval. Prior notification ensures that this service is the member’s first echocardiogram and that it will be properly reimbursed.

Q4. Generally, how far in advance may I submit a request for a PA/MND?
A4. Physicians may request a PA/MND up to two weeks prior to a planned cardiology imaging service.

Q5. How do I request a PA/MND?
A5. There are three ways to request a PA/MND from eviCore:

• Submit your request on eviCore.com.
• Call eviCore at 1-866-496-6200.
• Fax a completed fax submission form to 1-888-785-2480.

Q6. Where can I get fax submission forms for this program?
A6. Fax submission forms may be obtained from eviCore.com, or call eviCore at 1-866-496-6200.

Q7. What is the fastest way to obtain a PA/MND?
A7. The fastest way to obtain a PA/MND is to submit your request through, eviCore.com, along with the necessary clinical information and history. You can also call eviCore at 1-866-496-6200.

Q8. What information will I need to provide to eviCore?
A8. You will need to include the following relevant clinical information and history:

• Completed fax form (if faxing your request)
• Clinical office notes
• Consultation reports
• Previous diagnostic reports

For more information, visit eviCore.com, select Resources and then select Providers.

Q9. How can I verify if a PA/MND number has been issued?
A9. To verify this information, visit eviCore.com, or call eviCore at 1-866-496-6200.

Q10. Do PA/MND numbers expire?
A10. Yes. PA/MND numbers expire 45 calendar days from the date of the initial request.

Q11. Which patients require PA/MND?
A11. eviCore can advise which Horizon BCBSNJ patients require PA/MND for cardiology imaging services.

You may call eviCore at 1-866-496-6200 or visit eviCore.com to verify a member’s participation in this program.

Patients enrolled in Horizon NJ Health plans and programs require PA/MND for Cardiology Imaging services. Please visit the Horizon NJ Health eviCore healthcare webpage.

Q12. Which members are excluded from this program?
A12. Members enrolled in the following products are excluded from this program:

• BlueCard®
• Federal Employee Program® (FEP®)
• Indemnity
• Medigap
• Self-insured Administrative Services Only (ASO) groups (unless the groups have opted-in to the program)

There is also no prior authorization requirement for Small Group and Individual policyholders, but we recommend that cases be reviewed for medical necessity to help ensure timely and accurate claim payment.

Q13. Does this program apply to Horizon BCBSNJ members who have Medicare or another carrier as their primary coverage?
A13. This program does not apply to members for whom Horizon BCBSNJ is the secondary carrier.

Q14. Which places of service require PA/MND?
A14. This program applies to cardiology imaging services that are provided in a physician’s office, freestanding radiology site or in an outpatient setting. There is no PA/MND requirement for services rendered during an Emergency Room (ER) visit or inpatient stay.

Q15. Does this program apply if a patient receives services outside of New Jersey?
A15. If the facility participates with Horizon BCBSNJ directly (including those facilities within the contiguous counties of Delaware and Pennsylvania, including Lehigh County, PA), the physician must obtain PA/MND from eviCore.

If the facility does not participate with Horizon BCBSNJ, no PA/MND is needed. These claims process against the member’s out-of-network benefits (if applicable) or through the BlueCard program.

Q16. Do the same rules apply for non-participating rendering sites in the state of New Jersey?
A16. Yes, for members with out-of-network benefits, authorization should be obtained prior to services being rendered at a non-participating rendering site.

Q17. Are pediatric cardiologists excluded from the requirements of this program?
A17. Pediatric cardiologists are not required to provide clinical information, but they are still required to contact eviCore when each echocardiogram will be performed. This notification will ensure that claims will be processed correctly.

Q18. How quickly will PA/MND be provide d?
A18. General requests for commercial products will be resolved within three business days if all necessary clinical information is supplied. General requests for Medicare Advantage will be resolved no later than 14 calendar days after receipt of the request.

Provided that all necessary clinical information is made available, physicians who call eviCore will generally receive a PA/MND.

Q19. Are medically urgent requests accepted?
A19. Yes. eviCore will accept medically urgent requests (non-life-threatening requests that can wait up to 24 hours) for PA/MND. Urgent cases for members in commercial plans are handled within 24 hours of receipt of all necessary clinical information. Urgent cases for members in Medicare Advantage plans are handled no later than 72 hours after receipt of request. Urgent requests can be made by calling eviCore at 1-866-496-6200.

Emergency cases should be directed to the nearest ER. PA/MND is not required.

Q20. Can a health care professional discuss an adverse benefit determination made by eviCore?
A20. Yes, A health care professional may call the eviCore Peer to Peer Consultation line 1-866-241-6603 to discuss an adverse benefit determination made by eviCore for a patient enrolled in a Horizon fully insured commercial plan or Administrative Services Only employer group plan with an eviCore medical director.

Q21. How can I appeal an adverse benefit determination made by eviCore?
A21. To appeal an adverse benefit determination made by eviCore for Horizon Medicare Advantage or Braven Health℠ Medicare Advantage members you may fax a request to Horizon at 1-609-583-3028 or mail a request to:

To appeal an adverse benefit determination made by eviCore for Horizon fully insured commercial or Administrative Services Only employer group plans you may fax a request to eviCore at 1-866-699-8128 or mail a request to:

The Blue Cross® and Blue Shield® names and symbols and Federal Employee Program® and FEP® are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2022 Horizon Blue Cross Blue Shield of New Jersey.