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Prior Authorization Denials

Please use the form below if you would like to submit additional clinical information that justifies the medical necessity of a denied case. Requests not related to the submission of additional clinical information for a denied case will not be processed if submitted via the form below. Please note that only .PDF and .TIF file types can be supported.

Request Submission Form For Denied Cases Only

Thank you for submitting information. An EviCore representative will review the information submitted to determine the next level of review for this request. You will be contacted by phone or by fax if EviCore has any questions regarding your submission of information. If the level of review is an appeal you will receive a determination within the standard 30 days, or earlier based on state or federal requirements, as defined in the appeal rights of the initial decision notice. If you do not hear from EviCore within the standard 30 days, please call 800-792-8744, option 4.