What are my options following a denial?
Navigating the letter from EviCore: If the request from your healthcare provider doesn’t meet the evidence-based guidelines, you’ll receive a letter from EviCore letting you know it wasn’t approved and why. The “why” will include a reference to the medical guidelines in question, which are completely transparent and available on EviCore’s website for your review. Sometimes these letters may include an alternative course of action that would better meet the guidelines. To comply with certain health and regulatory requirements, these letters can be a bit wordy and confusing, so here are some options for potential next steps.
Option 1: Peer-to-Peer Discussion
Suppose you want an additional review of the initial request. In that case, you can ask your healthcare provider to set up a peer-to-peer discussion with one of EviCore’s medical directors, who will be from your provider’s specialty. This allows for the exchange of additional clinical information about your situation without the “red tape” of a formal appeal and often results in a better decision about whether to do a certain test, treatment or procedure. While this conversation must be conducted by your provider, he or she can easily schedule it online here at a time that’s convenient.
Option 2: Formal Appeal
The letter you receive will also outline how you can formally appeal the decision through a process with your health plan. It provides greater detail on the steps and process. Unlike the peer-to-peer with your provider, this process can be undertaken by the health plan member directly, but it can take longer and involve more steps.