Provider news

Suspended criteria for spine and musculoskeletal procedure auths in eviCore

The addition of eviCore to our Auth Request prior auth tool went live in June for all in-network musculoskeletal and spinal procedures, genetic testing, and advanced diagnostic imaging. Since the launch we have identified some technical issues that need to be resolved to follow the authorization guidelines outlined by Priority Health.

Some criteria suspended until Sept. 1

Effective immediately, criteria for the following will be suspended until September 1, 2017:

For all members/all products, two requirements for surgical spine surgeries are suspended:

  • 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-approve. To receive this approval, the authorization still needs to be submitted via Auth Request, which takes you to the eviCore portal when you enter a CPT code.

While we are resolving these issues

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.

Learn more about eviCore authorizations

All education materials as well as clinical guidelines supporting eviCore can be found at evicore.com/healthplan/priorityhealth.

Contact eviCore in three ways:

  • Online: evicore.com/healthplan/priorityhealth 
  • Phone: 844.303.8456 
  • Fax (spine/joint): 800.540.2406
Category: Authorizations