Oct 23rd 2019

Ask EviCore: What is Prior Authorization?

EviCore healthcare (EviCore) has partnered with your health plan to provide a variety of solutions to ensure that members get the right care when and where it’s needed. For your convenience we’ve collected some of the most common questions we’ve received from members, and we want to share some answers and information that might help put those subjects to rest.

Approaching Your Frequently Asked Questions

We often hear the questions: Who is EviCore? Why are they involved in my healthcare decisions? EviCore is a medical benefits management company which helps patients avoid unnecessary care that can be expensive and potentially unsafe. To make sure we’re always supporting the highest quality patient care, we apply the most current and authoritative evidence-based clinical guidelines through a process sometimes referred to as prior authorization.  Our professionals also support patients like you with solutions in advanced imaging including tests such as MRIs, CTs, and PET scans.

It’s no surprise that errors in diagnosis and treatment sometimes occur in the evolving healthcare system in our country. That is one of the reasons why prior authorization is needed. Our job is to help rein-in inappropriate, potentially unsafe care and unnecessary costs.

Did You Know?

In a recent study, based on 6 previously identified domains of health care waste, the estimated cost of waste in the US health care system ranged from $760 billion to $935 billion, accounting for approximately 25% of total health care spending, and the projected potential savings from interventions that reduce waste such as prior authorization, ranged from $191 billion to $282 billion, representing a potential 25% reduction in the total cost of waste.

EviCore’s solutions are designed to help patients get all the care they need, and none that they don’t. We are committed to transparency for both patients and their healthcare providers, and in the spirit of that, our evidence-based clinical guidelines are available for anyone to read on the EviCore website.

Clinical Guidelines? What Are Those?

The term “clinical guidelines” refers to the published criteria used by our medical staff to confirm or reassess the tests and treatment plans submitted by your provider. We review the submittals to determine if these decisions are medically appropriate and will be covered by your health plan. We apply the latest evidence-based data and information in using our guidelines; they are fully transparent and based on criteria from credible and innovative medical societies such as the American College of Cardiology and the American College of Radiology, as well as scientific evidence from recently published, peer-reviewed medical literature.

Our clinical guidelines are intended to support sound medical judgment, not replace it. As such, only an EviCore medical director or therapist can make the determination that requested care doesn’t meet evidence-based guidelines or is not medically inappropriate. In addition, we offer several channels, including peer reviews and appeals, that your provider can use to communicate effectively with us and advocate for any unique circumstances or needs you may have.

Do I Have to Do Anything?

Here’s the good news: the requests will all be made by your healthcare provider! And we’ll make sure that any waiting time is minimized whenever possible. We have the technologies and processes in place to ensure your provider receives any decision and/or alternative suggestions as quickly and easily as possible. Across all of our intake methods, more than 96% of initial requests are determined within 2 business days,

What if you’re having an emergency? Don’t worry, our solutions are applied only for standard (or non-emergency) care, so there is never a prior authorization requirement used in emergency circumstances.

If you have any further questions, we make a lot more information available on our patient page; both are available on our public site.