Request through eviCore Healthcare
For Implantable Cardiac Devices, Radiology/Imaging, Radiation Therapy or Musculoskeletal Services (large joint replacement, pain management and spine services), request authorization online with eviCore healthcare, or call 1-866-889-8056.
Accessing eviCore healthcare Online
If you experience difficulty connecting from our website to eviCore healthcare, please call our Web Security Help Desk at 1-800-278-1247. For Questions about using the eviCore healthcare website, please call eviCore healthcare directly at 1-800-918-8924 ext 10036.
Par Providers: All access to the eviCore portal requires sign-ons to be set up under a participating provider or directly linked to a participating provider. If a provider leaves network, or is no longer participating with the health plan, sign-ons must be updated to the current in-office participating provider. Additional authorizations for additional doctors in your group can be created after linking to eviCore and entering the group's tax ID number.
Referring Providers: Site Selection is not required for all preauthorized services. If it is required, you will be asked to provide this information during the authorization process on the eviCore web portal. services being requested for the inpatient setting will require additional data related to the facility during the creation process.
Radiology Urgent / Emergent Requests
This Urgent/Emergent policy only applies to the high end radiology codes that are prior authorized via eviCore
We do not require preauthorization for imaging studies for an emergency condition when a patient presents in a location other than emergency departments when, in the ordering physician's judgment, the patient's condition is emergent and directly ordering the study is the most appropriate course of action. Preauthorization is not required when a patient presents in an emergency department.
When emergent imaging studies are done in settings other than the ER, the rendering or ordering provider should call us within 72 hours after services are rendered to ensure that we process the claims appropriately. Please call the dedicated number at 1-800-536-2484, or send a fax to 1-800-292-5109.
Although most clinical emergencies present in the emergency room setting, occasionally emergent clinical conditions do present in the outpatient (facility or office) setting. Many physicians have asked us to create a specific list of diagnoses that would clearly divide emergent from non-emergent clinical situations. However, many medical conditions have diverse clinical presentations (e.g., rule out appendicitis, which can have both sub-acute and acute clinical presentations). Therefore, we do not believe a diagnosis code set is practical. As stated previously, when in the ordering physician's clinical judgment, the patient’s condition is emergent and ordering the study directly is the most appropriate course of action, we will not require preauthorization. The ordering physician should contact the radiologist directly and the radiologist should render the test.
Although these services will not require preauthorization, we will track and trend use of the "emergency" outpatient imaging process. If trends are identified that demonstrate higher utilization of emergency notifications, we will work with the ordering and/or rendering physicians to educate and clarify the process.
In order to identify why the utilization rate is higher for an individual provider compared to a peer group, we will review imaging studies for emergency conditions for clinical appropriateness on a retrospective basis.
The Health Plan will require pre authorization for urgent imaging studies performed in the outpatient setting.
It is strongly recommended that physicians call eviCore healthcare to initiate urgent requests. If the fax method must be used, physicians must clearly mark "URGENT" in capital letters on the fax cover sheet.
During eviCore healthcare regular business hours (Monday through Friday from 7 a.m. to 7 p.m.), the timeframe for decisions on urgent cases is three hours from the receipt of all necessary demographic and clinical information. For this reason, it is best to call eviCore healthcare to initiate urgent requests. If a patient requires urgent imaging after business hours, the physician may order the test and then contact eviCore healthcare within two business days to obtain authorization. When contacting eviCore National, be sure to indicate that the imaging was performed urgently and give the date of service to ensure that the authorization will be dated correctly.
Ordering providers are required to complete the online preauthorization information via the Web, fill out the preauthorization request fax forms or call eviCore healthcare for pre authorization. It is important to state that you are requesting preauthorization for an Univera Healthcare member.
Please have the following information on had to expedite the process:
- The patient's name, date of birth, phone number and insurance plan member ID number
- The ordering provider's name, provider ID number, fax and phone number
- The rendering provider’s information, including facility name, fax and phone number
- The CPT code and/or description of the test requiring pre authorization
- Patient data relevant to the request: signs and symptoms, test results, medications, related therapies, dates of prior imaging studies, etc.
When a procedure is approved, the ordering provider will contact the patient to schedule the procedure.
Appeals can be initiated by a member or the provider if there is an ongoing disagreement with the decision. Appeals for the preauthorization can also be expedited. Both pre- and post-service appeals must be submitted to the Health Plan. To appeal a denied authorization or claim, please contact us.
Medicare appeals for preauthorization denials are to be submitted through us. Members may begin the appeal process by contacting the dedicated Medicare Unit at 1-866-846-8643. Providers may contact our Provider Service department to initiate an appeal.
Commercial appeals for preauthorization denials are to be submitted directly to us. Providers may contact our Provider Service department to initiate an appeal. Claims appeals are conducted after a claim has been denied on the provider remittance you receive from the Health Plan. To appeal a denied claim, please contact us.