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Priority Health: eviCore Additional Education and Pay Information

October 12, 2017

We greatly appreciate your patience as we continue to optimize the eviCore experience. As you know, we are currently in the "educate and pay" phase, which gives you an opportunity to become more familiar with eviCore's clinical criteria. During this time we are also diligently working with eviCore to improve operational challenges.

Our process remains the same

As a reminder, our processes communicated on 8/22/17 remain the same, and will continue through the end of the calendar year:

  1.  No musculoskeletal or advanced imaging procedures will be denied based on clinical criteria. However:

 We continue to require a prior authorization as well as proper clinical documentation. While there will be no denials based on clinical criteria, we will be   using the data from these authorizations in the next few months to help determine our next steps

        2.  We have suspended peer-to-peer clinical reviews

        3.  We have implemented an "educate and pay" protocol

In place of peer-to-peer reviews, should an authorization request fail to meet eviCore's clinical criteria you will receive notification that clinical criteria have not been met, and available standards will be shared with you. Claims will still be paid as long as we have received your authorization.

"Educate and pay" process

We've heard your requests for additional information about the "educate and pay" process. Here is how it works:

Initial decisions are made via algorithm

  • If the case approves based on criteria, no further action is required, and an approval is issued.
  • If the case fails criteria, requiring nurse review, it is forwarded to the nurse queue.

Nurse Review

  • If the nurse can approve the case based on the information presented, or if additional clinical is obtained and supports medical necessity, the case will be approved.
  • If the nurse is unable to approve the case, it is forwarded for MD review.

MD Review

  • If the MD is able to approve the case based on the information presented, or if additional clinical is obtained and supports medical necessity, the case will be approved.
  • If the MD is unable to approve they will select the denial reasons specific to the case and a determination letter will be sent and payment of the procedure(s) will be authorized.

Timing

All requests are processed within three (3) business days after receipt of all necessary clinical information. We understand that this is an operational change from what you are used to and request your compliance and understanding.

Clinical Criteria Feedback

While it is our hope that operational solutions will improve the process, we understand that you may still have questions regarding the rationale and clinical evidence behind eviCore's authorization criteria. And you have the right voice your concerns. There are two ways to do that:

  1. Written feedback to eviCore
  2. Participation on one of their national advisory boards

 

We're here to help

If you have any additional questions or concerns, we want to hear from you. Please call us at 616.464.8432. We thank you for your continued engagement and patience.

John Fox, MD, MHA Vice President, Associate Chief Medical Officer