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Priority Health - Update on eviCore Processes and Solutions

September 20, 2017

Educate and Pay Program

As we continue to work with eviCore to identify solutions and address issues we have faced since the program implementation this summer, we are moving into a new phase, the Educate and Pay program. With the new program there are new communications you will be receiving from eviCore and there are new actions you will need to take.

As previously shared, all musculoskeletal and advanced imaging procedures that receive authorization denials for failure to meet eviCore's clinical criteria will be paid through the end of this calendar year; however, we will continue to require:

  1. Use of the eviCore tool to request a prior authorization
  2. Full submission of requested clinical documentation


Communications you can expect

To that end, when you submit your request for authorization, you may receive one of three responses:

  1. An auto approval via the web
  2. Request for additional clinical information
  3. Denial


If your request cannot be auto approved on the web, you will be faxed this message:

Message #1: The clinical information needed to determine medical necessity has not been supplied and is required to qualify for payment authorization under Priority Health's Educate and Pay program.

If you receive message #1, please submit the requested information to eviCore if you'd like your claim paid under the Educate and Pay program.


If you receive a denial from eviCore even after review of all clinical information, you will receive this message:

Message #2: Based upon the clinical information submitted for review, eviCore has determined that the service(s) requested above does not meet eviCore clinical guidelines for the following reason(s):
[eviCore will insert denial rationale evidence based guidelines appropriate for this patient's condition.]


Clinical guideline education

There will be no further action for you, as long you've submitted all necessary clinical information. Priority Health agrees to pay claims for all authorization requests - under the terms of the Educate and Pay program - even if the authorization does not meet clinical guidelines. The Educate and Pay Program covers services requested 8/21/17 - 12/31/17. In the meantime, please become familiar with eviCore's clinical guidelines.


Denied auths will be reversed

While we previously stated we would retroactively pay claims for musculoskeletal and advanced imaging claims submitted for dates of service from 8/1/2017 - we have also decided to approve all services that received denied authorizations since the implementation (6/19/17 - present). Your patients will now be able to receive those services. When eviCore reverses those services, letters will be sent to you and your patients with information to schedule services beginning next week.


We're here to help

If you have any concerns or on-going improvement suggestions - we want to hear from you. Please call us at 616.464.8432.

We thank you for your continued engagement and patience.

Your Priority Health Leadership Team