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Priority Health - New changes for some eviCore prior auths

July 26, 2017

  Priority Health has suspended  some criteria for spine/joint procedures.

The eviCore prior auth tool went live in June for all in-network musculoskeletal and spinal procedures, genetic testing, and advanced diagnostic imaging. Since the launch, Priority Health has identified some technical issues that need to be resolved to follow the guidelines originally outlined. 

Effective immediately, criteria for the following will be suspended until September 1, 2017.
For all members/all products, the two requirements for surgical spine surgeries that are suspended are:
• Patient must be six weeks smoke free
• Referral for, and psychological evaluation completed, based on Oswestry Disability Index (ODI) score > 40

For Medicare members only:
• All musculoskeletal (joint and spine) procedures will be set to auto approval. To receive this approval, the authorization still needs to be submitted via the eviCore portal.

Providers should continue to request authorizations through eviCore in the same method you have been.   However, as a reminder, urgent authorizations should be handled though a phone call, not the website.  Peer-to-peer consultations are encouraged to address any portion of the clinical guideline or authorization result.

Call eviCore at 844.303.8456 for peer-to-peer consults and urgent services normally authorized through eviCore healthcare.

This includes:
• Musculoskeletal (spine and joint) services & surgeries
• Advanced diagnostic imaging
• Genetic testing

eviCore staff are available Monday through Friday, 7 a.m. to 7 p.m. Eastern Time*. Outside business hours, leave a message. Urgent cases will be reviewed within 24 hours for Medicare and Medicaid/Healthy Michigan Plan members and within 72 hours for commercial group and individual members.

*Note: eviCore is closed on Jan. 1, Memorial Day, July 4, Labor Day, Thanksgiving and the Friday after, and Christmas day.
All education materials as well as clinical guidelines supporting eviCore can be found at evicore.com/healthplan/priorityhealth

Contact eviCore in three ways:
• Online
• Phone: 844-303-8456
• Fax: spine/joint: 800.540.2406