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