Denial of Preauthorization
Cases that do not meet medical necessity on initial nurse review are sent to a second-level physician for review and determination. If the eviCore physician makes a potentially adverse determination, the requesting provider is contacted and offered a peer-to-peer (P2P) review.
P2P must be requested within one business day or a denial letter is issued. Any additional clinical information that supports medical necessity must be received within one business day. If not, the determination is final, and the case is closed.
If the P2P process does not result in a reversal of the denial, eviCore issues a denial letter. The physician reviewer may suggest an alternate level of care and/or the appeals process. Once a service is denied, members and providers must file an appeal to have the request reviewed again.
Denial to Extend Services
Cases that do not meet medical necessity on concurrent nurse review are sent to a second-level physician for review and determination. If the eviCore physician makes a potential adverse determination, the requesting HHC agency is contacted and offered a P2P as described above.
Reconsideration Process (Commercial and Medicaid only)
A reconsideration is a post-denial, pre-appeal opportunity to provide additional clinical information. Reconsideration (P2P) must be requested within 14 days of the initial denial date. P2P requests can be made verbally or in writing. P2P is conducted with the referring physician and one of eviCore’s Medical Directors. P2P results in either a reversal or an uphold of the original decision. The requestor and the member are notified via mail and fax.
Appeals Process (Medicare, Medicaid, and Commercial)
Once a service has been denied, members and providers must file an appeal to have the request re-reviewed.
- Medicaid or Commercial members requesting to appeal a denial for HHC services should follow the instructions provided on the denial letter. Providers should submit appeal requests to eviCore via phone at 800-835-7064 (Monday through Friday, 8 a.m. - 6 p.m.) or fax at 866-699-8128.
- ·Medicare members may request an appeal of a denial for HHC services by following the instructions provided in the denial letter. Providers should follow the process in the Dispute Resolution for Medicare Plans chapter of the EmblemHealth Provider Manual.
Turnaround time after an appeal has been requested by the member is as follows:
- Expedited: up to 72 hours
- Standard: up to 30 days