Services Requiring Preauthorization
eviCore performs preauthorization review for PAC and direct admissions for the following:
- Skilled nursing facilities (SNF)
- Inpatient rehabilitation facilities (IRF)
- Long-term acute care facilities (LTAC)
Members should not be transferred from an inpatient hospital setting to an SNF, IRF, or LTAC setting without an eviCore preauthorization number. SNF, IRF, or LTAC facilities receiving program members without preauthorization should contact eviCore to verify approval before admission. Servicing facilities may obtain SNF, IRF, or LTAC preauthorization details:
- Online: evicore.com/provider
- Phone: 866-417-2345, option 3 for HIP, or option 5, then 1 for Provider, then 5 for PAC
Who Requests Preauthorization
- Hospitals are responsible for submitting the initial PAC preauthorization requests for members being discharged to an SNF, IRF, or LTAC.
- SNF, IRF, and LTAC providers are responsible for submitting:
- Concurrent review requests for existing admissions.
- Initial preauthorization requests for community referrals.
- Initial HHC service requests for members discharging from their facility with home health services.
How to Obtain a Preauthorization
Below is the information you need and the process for submitting preauthorization requests to eviCore.
The requesting provider should be prepared to submit:
- The appropriate eviCore request form
- Patient’s medical records
- Details such as:
- Admitting diagnosis
- History and physical
- Progress notes
- Medication list
- Wound or incision/location
eviCore offers two (2) convenient methods to request preauthorization:
- Call 866-417-2345, option 3 for HIP members, then option 1, then option 5 for PAC or Transitional Care; then either 2 for PAC or 3 for Transitional Care.
- Fax clinical documentation to 855-488-6275.
Preauthorization Time Frames
eviCore provides preauthorization for set periods of time by service type in the following ways:
Preauthorization |
Skilled Nursing |
Inpatient Rehab Facility |
Long-Term Acute Care |
Initial |
3 calendar days |
5 calendar days |
5 calendar days |
Concurrent |
7 calendar days |
5 calendar days |
7 calendar days |
Once clinical information is received, determinations are made within one (1) business day. If a peer-to-peer review is requested, an additional business day is granted. However, eviCore’s typical response time is less.
Once the determination is made, eviCore provides verbal notification to the requesting provider. Determinations are shared via Allscripts with providers that use Allscripts services. A copy of the determination letter is also faxed.
The initial preauthorization is valid for seven (7) days. During that time, inpatient hospitals must transfer the member to an SNF, IRF, or LTAC facility. If the member is not discharged within the seven (7)-day approval period, a new preauthorization is required.
SNF/IRF/LTAC Prior Approval Criteria
Criteria used by eviCore includes, but is not limited to:
- MCG Health (fka Milliman Care Guidelines) – for cases on and after Sept. 1, 2020
- McKesson InterQual® Criteria – for cases prior to and including Aug. 1, 2020
- Medicare Benefit Policy Manuals & Clinical Findings
Retrospective Reviews
eviCore accepts requests for retrospective reviews of medical necessity. Requests must be submitted within 14 calendar days from the date the initial service was rendered.
Concurrent Review
Facilities that fail to provide clinical updates and/or progress notes to the Managing Entity (concurrent review nurse or eviCore) are not reimbursed for unauthorized days.
Hospital Transfers
If an emergency occurs, the SNF, IRF, or LTAC facility should take all medically appropriate actions to safely transport the member to the nearest hospital, including the use of an ambulance, if necessary. eviCore must be notified when a member temporarily leaves and returns to an SNF, such as when the member is readmitted to the hospital.
Discharge Planning
The discharge planning process from all facility settings should begin as early as possible. This allows time to arrange appropriate resources for the member’s care.
Hospitals are responsible for submitting the initial preauthorization requests directly to eviCore for members being discharged to an SNF, IRF, or LTAC. For PAC services after an inpatient hospital stay (acute rehabilitation, skilled nursing facility stay, home care, and durable medical equipment), the eviCore concurrent review nurse facilitates preauthorization of medically necessary treatments if the member’s benefit plan includes these services.
For members in an SNF, IRF, or LTAC, the discharging facility is responsible for submitting the initial HHC service requests.
Notice of Medicare Non-Coverage (NOMNC) for Medicare Members
Important: For date extension (concurrent review) requests, SNFs should submit clinical information 72 hours prior to the last covered day. This allows time to issue the Notice of Medicare Non-Coverage (NOMNC). eviCore issues the NOMNC form to the provider. The provider is responsible for issuing the NOMNC to the member, having it signed and returning it to eviCore.
In accordance with CMS guidelines, the servicing provider issues the NOMNC no later than two (2) calendar days prior to the discontinuation of coverage or the second to last day of service, if care is not being provided daily.
The servicing provider is responsible for informing members who are cognitively impaired of the health care proxy of the end-of-service dates and the appeal rights. If the proxy is unable to sign and date the NOMNC, the staff member and witness who informed the proxy of the end date and appeal rights should sign and date the form, then fax it back to eviCore or send via the eviCore PAC Web Portal.