Evicore Prior Authorization Form: A Step-by-Step Guide

What is Evicore Prior Authorization?

Evicore's prior authorization is a critical healthcare utilization management process that ensures patients receive appropriate, evidence-based medical care while controlling healthcare costs. Evicore makes an evidence-based determination regarding whether a particular requested healthcare service or supply should be covered under a Member's healthcare benefits coverage, focusing primarily on medical imaging, cardiology procedures, and specialty treatments.

EviCore by Evernorth leverages clinical expertise, evidence-based guidelines, and innovative technologies to deliver best-in-class medical benefit management solutions that inform more effective, affordable treatment and site of care decisions for each patient's needs. Understanding this process is essential for healthcare providers to avoid treatment delays and ensure proper reimbursement.

Understanding Evicore Prior Authorization Requirements

Services Requiring Prior Authorization

Evicore primarily manages prior authorization for specific categories of healthcare services:

Advanced Imaging Services:

• Magnetic Resonance Imaging (MRI)
• Computed Tomography (CT) scans
• Positron Emission Tomography (PET) scans
• Advanced ultrasound procedures
• Nuclear medicine studies

Cardiology Procedures:

• Cardiac catheterization
• Echocardiograms
• Stress testing
• Cardiac MRI and CT
• Interventional cardiology procedures

Specialty Imaging:

• Non-OB ultrasound – including head & neck, pediatric, breast, abdomen & retroperitoneum, extremity, arterial & venous, and gynecological
• OB ultrasound – including obstetrical ultrasounds and fetal echocardiography

Health Plans Using Evicore

Multiple major health plans contract with Evicore for prior authorization management, including:

• Blue Cross Blue Shield plans
• UnitedHealthcare Medicare Advantage
• CareFirst
• Various Medicaid programs
• Commercial insurance plans

Step-by-Step Guide to Completing Evicore Prior Authorization

Step 1: Verify Patient Eligibility and Requirements

Before initiating any prior authorization request, healthcare providers must:

Check Insurance Coverage:

• Verify active coverage through the patient's insurance portal
• Confirm Evicore manages prior authorization for the specific service
• Review plan-specific requirements and limitations

Identify Authorization Requirements: Visit EviCore's Provider's Hub page and select the health plan and solution option for your case in the training section. The instructions on how to submit a case and a link to the correct portal to use will be provided.

Step 2: Gather Required Documentation

Successful Evicore prior authorization requests require comprehensive clinical documentation:

Patient Information Required:

• Complete member demographics and ID numbers
• Primary and secondary insurance details
• Referring physician information
• Contact information for scheduling

Clinical Documentation:

• Current diagnosis with appropriate ICD-10 codes
• Detailed medical history relevant to the request
• Previous imaging studies or treatment attempts
• Clinical notes supporting medical necessity
• Laboratory results or diagnostic reports
• Physician's treatment rationale

Service-Specific Information:

• Specific CPT/HCPCS codes for requested procedures
• Proposed imaging protocols or procedure details
• Facility information where the service will be performed
• Urgency level of the request

Step 3: Choose Your Submission Method

Evicore offers multiple channels for prior authorization submission:

Step 4: Complete the Prior Authorization Request

Provider Information Section:

• Provider name and National Provider Identifier (NPI)
• Practice address and contact details
• Tax identification number
• Provider specialty and credentials

Patient Demographics:

• Complete member information and insurance details
• Primary care physician information
• Emergency contact information
• Preferred language for communications

Clinical Justification:

• Clear medical necessity statement
• Treatment goals and expected outcomes
• Documentation of failed conservative treatments
• Risk-benefit analysis of the proposed procedure

Service Details:

• Specific procedures or imaging studies requested
• Proposed timeline for service delivery
• Facility location and capabilities
• Any special protocols or considerations

Step 5: Submit and Monitor Your Request

Submission Best Practices:

• Double-check all information for accuracy
• Ensure all required documentation is attached
• Note the submission confirmation number
• Document submission date and method

Tracking Your Authorization: EviCore is continually working to enhance your prior authorization (PA) experience by streamlining and enhancing our overall PA process. Monitor your request through:

• Online portal status updates
• Email notifications (if enrolled)
• Phone inquiries to customer service
• Automated status alerts

Processing Timeframes and Guidelines

Standard Processing Times

Routine Requests:

• Standard processing: 2-5 business days
• Complex cases: 5-10 business days
• Processing depends on documentation completeness

Expedited Processing:

• Urgent medical situations: 24-72 hours
• Same-day decisions for emergency cases
• Clinical urgency must be documented

Factors Affecting Processing Time

Documentation Quality:

• Complete clinical information expedites review
• Missing information causes delays
• Accurate coding prevents rejections

Request Complexity:

• Straightforward imaging requests process faster
• Complex multi-procedure requests take longer
• Novel or experimental procedures require additional review

Common Reasons for Evicore Prior Authorization Denials

Clinical Reasons

Insufficient Medical Necessity:

• Inadequate clinical documentation
• Failure to demonstrate symptom severity
• Missing conservative treatment attempts

Alternative Treatment Options:

• Less expensive alternatives are available
• Conservative management was not attempted
• Outpatient options for inpatient requests

Coverage Limitations:

• Service not covered under the specific plan
• Experimental or investigational procedures
• Cosmetic or elective procedures

Administrative Reasons

Documentation Errors:

• Incomplete patient information
• Incorrect procedure codes
• Missing provider credentials

Eligibility Issues:

• Patient not covered on the service date
• Benefits exhausted or limited
• Out-of-network provider restrictions

Strategies to Improve Approval Rates

Documentation Excellence

Clinical Best Practices:

• Provide a comprehensive medical history
• Include relevant diagnostic test results
• Document failed conservative treatments
• Use evidence-based treatment guidelines

Technical Accuracy:

• Verify all CPT and ICD-10 codes
• Ensure provider information is current
• Include all required forms and signatures
• Double-check patient demographics

Leveraging Evicore Resources

Clinical Guidelines: EviCore's clinical guidelines include background and supporting information and citations for sources used to develop the guidelines. Providers should:

• Review applicable clinical criteria before submission
• Align requests with evidence-based guidelines
• Reference published literature supporting treatment

Provider Education: EviCore highly recommends providers take full advantage of the online capabilities at https://www.evicore.com/provider to access:

• Training materials and webinars
• Clinical guideline updates
• Best practice recommendations
• Case study examples

Technology Integration and Digital Tools

Provider Portal Features

The Evicore provider portal offers comprehensive functionality:

• Real-time authorization status tracking
• Secure clinical document upload
• Electronic form submission
• Automated notifications and alerts

Mobile Access

Healthcare providers can manage authorizations through mobile-optimized interfaces:

• On-demand status checking
• Quick reference to clinical guidelines
• Emergency contact information
• Document capture capabilities

Future Developments and Industry Trends

Electronic Prior Authorization Evolution

The healthcare industry continues advancing toward streamlined electronic processes:

• Real-time decision support systems
• Artificial intelligence integration
• Predictive analytics for approval likelihood
• Automated clinical documentation review

Regulatory Landscape

Staying informed about regulatory changes is crucial:

• CMS prior authorization reforms
• State-specific requirements
• Industry standardization efforts
• Quality measurement initiatives

Best Practices for Healthcare Providers

Staff Training and Education

Ongoing Education:

• Regular training on Evicore procedures
• Updates on clinical guideline changes
• Technology platform proficiency
• Documentation best practices

Quality Assurance:

• Regular audit of submission accuracy
• Tracking of approval and denial rates
• Continuous process improvement
• Staff feedback and coaching

Patient Communication

Setting Expectations:

• Explain the prior authorization process
• Communicate realistic timelines
• Discuss alternative treatment options
• Provide contact information for questions

Managing Delays:

• Proactive communication about status
• Alternative scheduling options
• Emergency procedure protocols
• Patient advocacy support

Conclusion

Successfully navigating the Evicore prior authorization process requires understanding requirements, maintaining high documentation standards, and leveraging available technology tools. EviCore's approach is not to deny care that is needed but rather to redirect providers and patients to more appropriate testing and treatment options, which helps ensure safety and maximize value.

Healthcare providers who invest in proper training, maintain comprehensive documentation practices, and utilize Evicore's digital tools will experience higher approval rates and faster processing times. The key to success lies in understanding that prior authorization serves an important role in ensuring appropriate, evidence-based care while managing healthcare costs effectively.

By following this comprehensive guide and staying current with Evicore's evolving processes and requirements, healthcare providers can minimize administrative burden while ensuring their patients receive necessary medical care without unnecessary delays.

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Frequently Asked Questions (FAQ)

Q: How long does an Evicore prior authorization take? 

A: Standard requests typically process within 2-5 business days, while urgent requests may be approved within 24-72 hours. Processing time depends on documentation completeness and request complexity.

Q: Can I submit a prior authorization request online? 

A: Yes, Evicore's preferred submission method is through their secure online portal at evicore.com/provider, which provides 24/7 access and real-time status updates.

Q: What happens if my prior authorization is denied? 

A: You have the right to appeal the decision through Evicore's formal appeal process. Include additional clinical documentation and evidence supporting medical necessity.

Q: Do I need prior authorization for emergency imaging? 

A: Emergency services typically don't require prior authorization, but retrospective review may apply. Contact Evicore as soon as possible after emergency service delivery.

Q: How do I check the status of my prior authorization request? 

A: Monitor your request status through the Evicore provider portal, automated email notifications, or by calling customer service directly.

Q: Which health plans use Evicore for prior authorization? 

A: Multiple major insurers contract with Evicore, including various Blue Cross Blue Shield plans, UnitedHealthcare, CareFirst, and Medicaid programs. Check with the specific health plan to confirm Evicore involvement.