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Sometimes the tests, treatments, and/or procedures ordered by your healthcare provider must undergo a process called prior authorization (PA). (See how it works below.) PA helps ensure that the healthcare your provider requests is as effective, economical, and appropriate as it should be. 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.

About eviCore

Your health plan is partnering with eviCore healthcare (eviCore), a medical benefits management company, to ensure you get the best possible care. eviCore’s clinical team includes 300 physicians and 800 nurses. Their sole job is to protect your health and your wallet by making sure your care aligns with the most up-to-date, evidence-based medical guidelines.

Our entire team of experienced healthcare experts are committed to making a positive impact on the care you receive. We are able to effectively connect you, your provider, and your health plan together.

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How does prior authorization work?

  1. Step 1

    You visit your healthcare provider, who then requests a test, treatment, or procedure.

  2. Step 2

    The request is sent to eviCore for prior authorization. Although the Web is our preferred channel, phone or fax is also acceptable.

  3. Step 3

    Evidence-based clinical guidelines are applied to the request to make sure it’s in line with the current science and medical best practices. If the request is approved, the patient receives the care requested by the provider.

  4. Step 4

    If more information is needed to make a prior authorization decision, the request is sent to a nurse for further review. If the request is approved, the patient receives the care requested by the provider. 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.

  5. Step 5

    During the medical director review, the following may occur with the request.

    (1) The request doesn’t meet the evidence-based clinical guidelines-only a medical director can make the determination that a request doesn’t meet the evidence-based clinical guidelines. If this occurs, the patient is notified, and alternative treatment options may be provided.

    (2) A peer-to-peer review is scheduled. A peer-to-peer review means that the requesting provider meets directly with an eviCore medical director (of similar medical specialty) to review the request more closely. If the patient’s healthcare 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?

  1. 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.

  2. 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.

  3. 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.

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Frequently Asked Questions

What is prior authorization?

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.

Who is eviCore?

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.

Why was my test, treatment, and/or procedure not approved?

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.

What are my options following a denial?

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.

What are clinical guidelines?

eviCore has a variety of solutions to ensure you get the most appropriate care. Each solution uses evidence-based medical guidelines to help patients avoid unnecessary tests, treatments and/or procedures that research has shown are ineffective, dangerous, and costly. eviCore's evidence-based medical guidelines are based on information from medical societies like the American College of Radiology and the American College of Cardiology and the latest peer-reviewed medical journals. These evidence-based medical guidelines are intended to support and enhance sound medical judgement. Seasoned medical professionals supporting eviCore as an in-house physician or therapist can make determinations that care you receive is medically inappropriate and help provide alternative solutions. While evidence-based medical 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.

What is the risk if a patient receives too many medical tests?

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.

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