Patient Resources

Prior Authorization is a process that helps ensure that the test, treatment, and/or procedures your provider requests is as effective, affordable, and as medically appropriate as it should be.

The care you receive should always be backed by the latest scientific evidence; that way, we make sure that the care you receive is safe as well as clinically and financially right for you. For example, imagine that you take your car to an auto repair shop with an oil leak. After some significant testing, the repair shop also identifies that you need new tires and a new engine leaving you with significantly more cost and services than you initially had intended.

eviCore is a medical benefits management company who works with health plans to help their members, like you, avoid unnecessary care that is costly and potentially unsafe. We do that by applying the latest evidence-based medical guidelines through a process referred to as prior authorization. eviCore’s clinical team includes 300 physicians and clinical therapists and nearly 800 nurses. Their sole job is to protect your health and your wallet by making sure the care you receive is backed by the latest science.

These are some of the most common reasons that a test, treatment, and/or procedure might not be approved:

More clinical information is needed: There are times when eviCore needs to receive more clinical information from your healthcare provider, like medical history or tests you’ve already had, to determine whether the request meets the latest evidence-based medical guidelines.

More conservative therapy should be tried first: Evidence-based guidelines often point to trying conservative solutions like rest, ice, or elevation first before moving on to more invasive options that involve scans, scopes, and needles.

A preliminary test is lacking: In some cases, the request of treatment requires that a precursor test – like an ultrasound or x-ray – should always be tried prior to a more complicated procedure like advanced imaging (such as an MRI or a CT scan) or surgery.

Navigating the letter you receive(d) from eviCore: If the request from your healthcare provider doesn’t meet the evidence-based guidelines, you’ll receive a letter from eviCore letting you know it wasn’t approved and why it was denied. The “why” will include a reference to the medical guidelines in question, which are completely transparent and available on eviCore’s website for your review. When possible, these letters may include an alternative course of action that would better meet the clinical guidelines. In this situation, we are providing you with some options for potential next steps.

Option 1: Peer-to-Peer Discussion
If you want an additional review of the initial request, you can ask your healthcare 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 time that is convenient to them.

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 and process 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, dangerous, 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 clinical guidelines are intended to support and enhance sound medical judgement. 

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 overtesting with radiology include, but are not limited to:

• Additional testing because of a false positive test result
• 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.