Services Requiring Preauthorization
Preauthorizations are specific to the CPT-4 procedure code and site location. Refer to Clinical Corner for services (and CPT-4 codes) requiring preauthorization. Each requires a separate preauthorization. They are valid for 45 days from the approval date.
Claims are denied, and the member is not held liable for payment if:
- A preauthorization is required but not obtained for the CPT-4 code performed.
- Procedures are performed at a service location other than the address on the preauthorization issued.
Who Requests Preauthorization
The practitioner developing the patient’s treatment plan is responsible for obtaining the preauthorization. If the referring and servicing practitioners are different, the servicing practitioner is encouraged to confirm that a preauthorization is on file before rendering services.
PCPs referring patients to a cardiologist for testing are responsible for initiating the preauthorization. If the cardiologist is already treating the patient, the cardiologist should initiate the request. The servicing practitioner is ultimately responsible for ensuring all applicable cardiology imaging procedures at the applicable service location are authorized.
How to Request Preauthorization
Clinical worksheets are available to assist in collecting all the required information for preauthorization. The worksheets include clinical questions the practitioner must answer during the initial preauthorization review.
You may submit preauthorization requests in one of three ways:
- Online for all programs: evicore.com
- By faxing the completed worksheet specific to the procedure being requested:
- For radiology: 800-540-2406
- For cardiology imaging: 888-622-7369
- By phone (Representatives are available Monday through Friday, from 7 a.m. to 7 p.m. ET.)
- HIP, EmblemHealth Insurance Company (formerly HIPIC), and Bridge members: 866-417-2345
- EmblemHealth Plan, Inc. (formerly GHI) members: 800-835-7064
eviCore is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving Day, and Christmas Day. Multiple requests may be handled on one call.
Please have the following information available when you call:
- Information requested on the applicable worksheet.
- Patient's full name, member ID number, and insurance information.
- Ordering practitioner information.
- Rendering site information.
- Exam(s) requested.
- Working diagnosis or rule-out.
- Signs and symptoms, as well as their duration.
- Previous imaging studies performed, corresponding results, or pertinent lab results.
- History of prior treatment methods, drugs, surgery or other therapies, as well as duration of prior treatment.
- Any other information indicating the need for the procedure.
- Cancer type being treated with radiation therapy.
- Treatment plan specifics.
Expedited Approval Requests
evicore.com cannot be used for expedited approval requests. They must be processed through the call center. See the How to Request Preauthorization subsection of this chapter.
Urgent Requests
If the treatment is medically urgent and must be performed outside eviCore’s business hours, the physician may deliver treatment. The preauthorization request (with supporting clinical documentation) must be submitted within two (2) business days of treatment. Urgent requests are reviewed against medical necessity criteria; approval is issued if they are met. eviCore completes urgent requests within 24 hours of the request’s receipt.
evicore.com cannot be used for urgent approval requests. They must be processed through the call center. See the How to Request Preauthorization subsection of this chapter.
Non-Urgent Requests
Non-urgent requests are completed within three business days of eviCore’s receipt of all necessary information, or within the time frames otherwise required by the member’s benefit plan (see Standard Pre-Service Reviewin the Utilization and Care Management chapter).
A physician with office hours later than eviCore’s call center may initiate a case through evicore.com and the request will be processed on the next business day.
Modifying a Preauthorization Request
If it becomes necessary to change or update the procedure after preauthorization is obtained, eviCore must be contacted no later than 48 hours after the modified procedure is performed. If the preauthorization for the modified procedure is not updated, and the claim does not match the authorized procedures, the claim is denied, with no member liability.
Verifying the Preauthorization Status
To verify the status of a preauthorization request, either call the applicable number as described in the How to Request Preauthorization subsection of this chapter or visit the Authorization Lookup section on evicore.com.