Ask EviCore: Roles and Responsibilities of EviCore & Health Plans
Hi, I’m Mark Tate, and my team is responsible for making providers’ experience with EviCore easier, faster, and more collaborative. We invite you to share your feedback and recommendations.
This edition of Ask EviCore focuses on a topic that many of you have asked about—the respective roles and responsibilities of EviCore and the health plans.
Health plans partner with EviCore on a variety of programs to ensure that patients get the right care when and where it’s needed. Each program uses evidence-based clinical guidelines to help patients avoid unnecessary tests, treatments, or procedures that research has shown are unnecessary, ineffective, or even potentially dangerous.
How can a provider office find out what procedures need a prior authorization from EviCore?
There are several ways a provider office can determine which procedures need prior authorization from EviCore.
First, each health plan provides a provider resources website listing the CPT codes that apply to each individual health plan, indicating which tests, treatments, or procedures need prior authorization. These websites are not publicly available, but providers can obtain the web address from the health plan. These websites are also shared whenever a provider office engages in any of EviCore’s provider orientation sessions, training sessions, or implementation program trainings. Click here to register for future orientation and training sessions.
Second, a provider office can visit the EviCore portal and start a prior authorization request for a patient. If the CPT code is a selectable option in the list on the portal, then it requires a prior authorization; if the CPT code is not available on the code list, then a prior authorization from EviCore is not required.
Finally, the provider office can also verify prior authorization requirements directly with the patient’s health plan.
How can providers tell what procedures require a prior authorization from EviCore vs. a prior authorization from the health plan? Are there reference guides available somewhere?
As mentioned above, the Health Plan Provider Resource websites provide a list of CPT codes that indicate which tests, treatments, or procedures require a prior authorization from EviCore—and these websites are full of valuable information. The provider office can also visit the EviCore portal and start a prior authorization request for a patient. If the CPT code is available, then a prior authorization from EviCore is required. In addition, the provider office can contact the patient’s health plan directly to verify whether a prior authorization is required.
If our provider office has questions, who should we call – the health plan or EviCore?
If you have questions, call EviCore and our team will be happy to help you! We even developed a special tool on our website to help you find the right person to answer your questions. From the first drop-down menu under “Learn how to…”, click on “Find Contact Information.” You will then be prompted to select the health plan and EviCore solution from the next two drop-down menus, respectively. After selecting the information and pressing “Start,” you will see specific contact details.
When a health plan makes a change about whether a prior authorization is required, or what documentation is required, where can we find that information?
When there are changes made to prior authorization requirements or documentation—including whether a prior authorization is no longer needed—the health plan notifies providers of these changes through provider announcement letters. This information is also shared during EviCore’s Provider Orientation Sessions. Click here to register for future orientation and training sessions. The Health Plan Provider Resource website is the best resource for which tests, treatments, or procedures require a prior authorization from EviCore. CPT codes change annually, so it is important for providers to frequently check the Health Plan Provider Resource website.
We encourage you to continue to share your feedback, suggestions, and questions about our prior authorization process and this newsletter. Jackie Jenkins, the National Provider Advocate on my team, can be reached via email at providernewsletter@evicore.com. I look forward to continuing to address your questions and comments through future editions of the Ask EviCore column. Thank you for working with EviCore so that together we can help ensure your patients get the best possible care.