Information required for advanced diagnostic imaging authorizations

For each request for prior authorization of high-tech diagnostic radiology services, eviCore healthcare will require:

• Patient information: Name, DOB, plan name, contract number from the patient's Priority Health ID card
• Ordering physician's name, NPI number, tax ID (TIN)
• Place of service 
• Imaging provider name, NPI, TIN, street address and fax number
• Type of service, CPT/diagnosis codes
• Reason (indication) for the imaging procedure, and/or ICD-10 CM diagnosis code
• Patient's clinical symptoms, including intensity and duration
• Relevant clinical notes: Imaging/X-ray reports, patient history, physical findings