CLINICAL CRITERIA
Chemotherapy Review Criteria
Genetic and Molecular Testing Review Criteria
Radiation Therapy Review Criteria
Utilization Management Review Criteria
Medicare Criteria Hierarchy

PRIOR AUTHORIZATION FORMS
OncoHealth Chemotherapy Prior Authorization Request Form (US Mainland)
OncoHealth Chemotherapy Prior Authorization Request Form (Puerto Rico)
OncoHealth Radiotherapy Prior Authorization Request Form (US Mainland)
OncoHealth Radiotherapy Prior Authorization Request Form (Puerto Rico)
OncoHealth Genetic or Molecular Testing Prior Authorization Request Form (US Mainland)
OncoHealth Genetic or Molecular Testing Prior Authorization Request Form (Puerto Rico)
Log in to the Provider e-Prior Authorization Portal

STATE SPECIFIC PRIOR AUTHORIZATION FORMS 

Texas:
Texas Standard Prior Authorization Request Form for Health Care Services
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

Massachusetts:
Massachusetts Standard Form for Chemotherapy and Supportive Care Prior Authorization Request

CLINICAL CRITERIA INQUIRIES
The clinical criteria that Oncology Analytics, Inc. dba OncoHealth uses for utilization management are available upon request by contacting us at:
7000 Central Parkway, Suite 1750
Atlanta, GA 30328
(888) 916-2616, Option 1

UM AFFIRMATIVE STATEMENT
Oncology Analytics, Inc. dba OncoHealth affirms that:

  1. UM decision making is based only on appropriateness of care and service and the existence of coverage;
  2. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage; and
  3. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

MEDICARE CRITERIA HIERARCHY
Oncology Analytics, Inc. dba OncoHealth utilizes the following hierarchy order of criteria to make medical necessity determinations.  The list identifies the Medicare resource guidelines and the order in which criteria should be reviewed.  Other lines of business may have similar hierarchies which are utilized.

 

  1. Medicare National Coverage Determination (NCD):
  1. Medicare Local Coverage Determination (LCD):
  1. Health Plan Policy
  1. Nationally approved and recognized medical coverage criteria/guidelines:
  1. Nationally recognized literature/journals: Other uses of drugs and biologics may be considered medically accepted if supported as safe and effective according to peer-reviewed articles from one of the following journals:

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