What are my options when a case is denied?
Post-decision options for partial or full denial decisions may vary based on the denial reason, health plan, member’s line of business or even the member’s residing state. Depending on these factors and the amount of time that has lapsed since the denial decision, you may be able to have a decision reevaluated via a Peer to Peer Consultation, formal Reconsideration or Appeal. During each of these stages, you may also be able to provide additional clinical information verbally or in writing. In some cases, you might also be able to accept an alternative recommendation for a test or procedure that may be more appropriate for the patient’s condition.
In order to understand exactly what post-decision options are available for a specific case, as well as who manages each available option, you may contact EviCore Healthcare via the telephone number provided to you on the determination notice. EviCore’s Physician Support Unit will assess the case to determine what options are available at the time of your inquiry and will provide you with guidance on how to exercise the available options. Physician Support Unit agents will also be able to assist you in scheduling a Peer to Peer Consultation, if desired. It is important to note that Peer to Peer Consultations may always be requested to understand a denial decision. However, depending on the post-decision option available, these conversations might not always have the potential to overturn a denial decision. EviCore’s Physician Support Unit agents will let you know when a Peer to Peer Consultation is considered educational only and provide you with an alternative option to have the decision considered for overturn, if applicable.
In some instances, you may also be able to query post-decision options available to you online via our Provider Portal. If this is an available option for the case in question, you will have the ability to select “P2P/Post-Decision Options” or “Accept Alternative Recommendation.” These selections can be found below Case Status on the Authorization Lookup tab on the provider portal.