Ask EviCore: Denied Requests
Hi, I'm Mark Tate, and I lead EviCore's Provider Experience team. We want to continuously learn from you and improve our interactions so that your experience with EviCore is easier, faster, and more collaborative. To begin the new year, our January Ask EviCore feature is focused on adverse determinations and navigating the path forward with your patient after a request has been denied. We receive a lot of questions about this topic, so we've answered some of the most frequently asked questions below. Together, we can ensure your patients get the right test, treatment or procedure for their needs. Keep submitting your questions, and I look forward to answering them in future editions of this newsletter.
What do I tell my patient when their case is denied?
Patients should be encouraged to review the determination letter they receive by mail, to understand (1) the reasons the request was determined to be inappropriate, and (2) the post-decision options that are available to them. As their provider, however, you too should review the determination and options available, as you may be able to act on your patient's behalf.
What are my options when a case is denied?
Post-decision options for partial- or full-denial decisions can vary, based on the reason for the denial, the health plan, the 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 will 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.
To understand exactly what post-decision options are available for a specific case, as well as who manages each available option, you can 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 can always be requested to understand a denial decision. However, depending on the post-decision option available, these conversations might not always offer the potential for overturn of 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 that includes the potential for overturn, if applicable.
In some instances, you may also be able to query your available post-decision options 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.
How can I submit more clinical information if needed?
Providers are encouraged to submit all relevant clinical information for consideration upon case initiation. After a decision has been made, you will have the option to provide additional clinical information as part of a post-decision event. Additional clinical information can be uploaded via EviCore's provider portal, or can be faxed to EviCore via the fax number provided to you for the specific health plan program.
How do I start an appeal?
Appeal options may vary, based on the reason for the denial, the health plan, member's line of business, or even the member's residing state. Information regarding appeal options, and with whom an appeal should be filed, can be found in the determination letter. You can also contact EviCore healthcare via the telephone number provided on the determination letter, to understand what appeal options are available at the time of your inquiry. In some instances, you may also be able to find this information 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." This option can be found beneath Case Status on the Authorization Lookup tab on the provider portal.
How do I schedule an online clinical consultation following a denial?
Peer-to-Peer Consultations can be requested online here.
You are invited to continue to share your feedback, suggestions, and questions about our Prior Authorization process and this newsletter. Email providernewsletter@evicore.com and Jackie Jenkins, the National Provider Advocate on my team, will connect with you soon.
Thank you for your continued partnership with EviCore.