Prior Authorization
A process by which EviCore makes an evidence-based determination regarding whether a particular requested healthcare service or supply should be covered under a Member’s healthcare benefits coverage (which may include, among other items, Medical Necessity determinations). In addition, may include automated processes, processes and procedures relating to the level and intensity of review applicable to particular services and Providers, and processes for authorizations without review, and consistent with Applicable Laws.
EviCore content reference(s):