Sometimes the tests, treatments, or procedures requested by your health care provider need prior authorization (PA) to ensure they are effective, affordable, and medically appropriate. After all, the care you receive should always be backed by the latest scientific evidence. Otherwise, it can be inappropriate and expensive, and lead to other unsafe procedures and treatments. See how PA works.
Your health plan is partnering with EviCore healthcare (EviCore), a medical benefits management company, to ensure you get the best possible care. Our clinical team includes 500+ physicians and 1,200+ clinicians who protect your health and your wallet by making sure your care aligns with the most up-to-date, evidence-based clinical guidelines. If care is deemed inappropriate, EviCore can recommend appropriate alternative solutions to your provider.
Our entire team of experienced health care experts are committed to making a positive impact on the care you receive. We can effectively connect you, your provider, and your health plan together.
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How does prior authorization work?
You visit your healthcare provider, who then requests a test, treatment, or procedure.
EviCore applies evidence-based clinical guidelines to the request to make sure it follows the current science and medical best practices. If approved, you receive the requested care.
If more information is needed to make a PA decision, the request is sent to a nurse for further review. If approved, you receive the requested care. If the nurse isn’t able to approve the request based on the available information, the request is sent to a medical director for final review.
During the medical director review, the following may occur:
- The request doesn’t meet the evidence-based clinical guidelines. Only a medical director can make this determination. If this occurs, you will be notified and alternative treatment options may be provided.
- A peer-to-peer review is scheduled. The requesting provider meets directly with an EviCore medical director of similar medical specialty to review the request more closely. If the patient’s health care provider can offer additional information, a decision about the request can be made.
My provider's request for a test, treatment, or procedure was denied. Now what?
Navigating the letter you receive(d) from EviCore
If the request from your health care provider does not meet evidence-based guidelines, you will receive a letter from EviCore letting you know why the request was not approved. The letter will include a reference to the clinical guidelines in question, which are transparent and available here for your review. When possible, the letter may include an alternative course of action that would better meet the clinical guidelines, as well as some potential next steps.
Option 1: Peer-to-Peer Discussion
If you want an additional review of the initial request, you can ask your health care 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 discussion allows for the exchange of additional clinical information regarding your medical situation without the “red tape” of a formal appeal. Peer-to-peer discussions often result in a more clinically appropriate decision about whether to do a certain test, treatment, and/or procedure. While this discussion must be conducted by your provider, he or she can easily schedule it online at a convenient time.
Option 2: Formal Appeal
The letter you receive(d) will also outline how you can formally appeal the request decision through your health plan’s process. The letter will also provide greater detail on the steps for the appeal. Unlike the peer-to-peer discussion your provider can engage with, this process can be undertaken by you, the health plan member, but it may take longer and involve more steps.
EviCore has a variety of solutions to ensure you get the most appropriate care. Each solution uses evidence-based clinical guidelines to help patients avoid tests, treatments, or procedures that research has shown are unnecessary, ineffective, unsafe, or overpriced. EviCore's evidence-based clinical guidelines are based on information from medical societies such as the American College of Radiology and the American College of Cardiology, as well as the latest peer-reviewed medical journals. These guidelines are intended to support and enhance sound medical judgment.
The guidelines are one of the tools that expert medical professionals who support EviCore as an in-house physician or therapist can use to determine whether the care you receive is medically appropriate. If care is deemed inappropriate, they can offer appropriate alternative solutions. While evidence-based clinical guidelines are generally developed from large-scale studies and statistics, EviCore provides ready, clear channels, including peer reviews and appeals, by which clinicians can advocate for a patient’s unique circumstances or needs.
Some common radiological tests are frequently ordered inappropriately, i.e., without an indication that is supported by scientific evidence. To help navigate these challenges with a vast selection of diagnostic tools, EviCore provides feedback to requesting physicians with explanations on when a request is appropriate, and when a request may be denied because it’s not the best treatment option for the patient. In addition to being more costly or potentially endangering a patient, some tests can also produce erroneous results known as "false positives," which might lead to additional unnecessary testing and sometimes the treatment of benign conditions. Additional risk factors of too much testing with radiology include, but are not limited to:
- Interference with pacemakers or other internal devices
- Magnetic pull that has the potential to tear out aneurysm clips, piercings, or shrapnel
- Unnecessary surgery
- If performed with contrast:
- Kidney damage
- Allergic reaction to contrast
- Deposit of IV contrast that does not always leave the brain
- Excessive and repeated exposure to radiation
It is in everyone’s best interest that we limit these potential testing risks when a conservative approach or less invasive test may produce the desired results.