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Priority Health - Update on eviCore authorizations

August 28, 2017

The implementation and launch of eviCore was meant to provide our provider partners a seamless, evidence-based tool that helps provide your patients the right care at the right time - ensuring the best health outcomes.

While we have been working hard to ensure a smooth adoption of eviCore, we apologize that we have fallen short of our promise to you. We know there has been unnecessary frustration, delays and confusion as a result and we are sorry. Thank you to all of our network partners who have been working so diligently with us to identify and correct technological issues, who have allowed us into their practices to train, troubleshoot, and observe, and to those who continue to engage with our medical leadership. We want you to know that we have heard you, and in turn are working with eviCore to identify solutions and address any new issues if they arise.

Effective today, we’re instituting a variety of tactics to alleviate the highest impact pain points, while we continue to gather data and evaluate the operational effectiveness of eviCore.

1.  Clinical criteria denials have been lifted through 12/31/17:

All musculoskeletal and advanced imaging procedures that received denials for clinical criteria will be paid through the end of this calendar year.
a. We will continue to require a prior authorization as well as proper clinical documentation. However, there will be no denials based on clinical criteria. Over the next few months, the data from these authorizations will be crucial in determining our next steps.
b. We will retroactively pay claims for musculoskeletal and advanced imaging claims submitted for dates of service from 8/1/2017 until now. We have generated a list of claims denied for failure to meet eviCore’s clinical criteria, and these will be reviewed internally and reprocessed.
c. For Medicare Advantage members, authorizations for musculoskeletal procedures had been previously setup to auto-approve through 9/1/17. This auto-approval is being extended through 12/31/17 to maintain consistency.

2.  Suspend peer to peer clinical reviews beginning 8/22/17 through 12/31/17:

The peer to peer review requirement for denied authorizations is being suspended on 8/22/17. Any previously scheduled peer to peer reviews can continue, but no new peer to peer reviews will need to be scheduled. If a provider receives a denied authorization pending peer to peer review any time between now and 12/31/17, Priority Health will handle the reprocessing of that case. Please call us at 616.464.8432 and leave a message with the eviCore case number, a brief overview of the case, and caller contact information. After review, we will manually overturn peer to peer based denials. 

3.  Implement an "educate and pay" protocol starting 8/22/17 through 12/31/17:

In place of the peer to peer review between now and 12/31/17, should an authorization request fail to meet eviCore’s clinical criteria, the provider will receive notification that clinical criteria has not been met, and will be directed to available standards. Because we have lifted the clinical criteria requirements through the end of the year, the claim will still be paid as long as we have received the authorization. We anticipate the “pay and educate” protocol to begin with authorizations starting 8/22/17.

These approaches, in addition to the increased training that has been available in the last couple of weeks, represent our first steps in addressing network concerns for eviCore operationalization. Internally, we continue to work with eviCore to resolve functional issues that contribute to the large administrative burden.

If your experience with eviCore is inconsistent with the above outlined changes once they are effective, we want to hear from you. Please call us at 616.464.8432 with concerns or improvement suggestions.
We thank you for your continued engagement and patience.

Your Priority Health Leadership Team