Only one approved PA is required for both the technical and professional components of the service, even when billed by different providers.
Providers are required to use eviCore healthcare forms to submit PA requests for advanced imaging services via fax. Faxes received of any other forms will be returned to the provider unprocessed. eviCore healthcare forms are available through the eviCore healthcare Portal or by calling eviCore healthcare.
eviCore healthcare will make a decision regarding a provider's PA request within 20 business days of the receipt of all the necessary information; however, eviCore healthcare is frequently able to make a PA determination immediately. If eviCore healthcare is unable to immediately approve a PA request, the PA request will be elevated to a nurse consultant for additional review. If the nurse consultant is unable to approve the PA request, the PA request will be elevated to a physician consultant. Only a physician consultant can deny a PA request based on their determination that the request does not meet clinical guidelines.
PA requests for advanced imaging services are approved by eviCore healthcare for a period of 60 calendar days from the grant date. The provider who submitted the PA request receives a copy of a PA confirmation fax when a PA request for a service is approved. Ordering providers are encouraged to share the information on the PA confirmation fax with the provider who renders the service. Providers may render the approved services beginning on the grant date.
The PA confirmation fax identifies the specific procedure codes that are approved. The provider who renders the service may substitute and perform a service defined by a different procedure code without contacting eviCore healthcare only when the substituted procedure code is considered a "downcode," as in the following situations:
For example, if the PA confirmation fax authorizes procedure code 70470 (Computed tomography, head or brain; without contrast material, followed by contrast material[s] and further sections), the provider rendering the service may substitute and render procedure code 70450 (Computed tomography, head or brain; without contrast material) or 70460 (Computed tomography, head or brain; with contrast material[s]). This would be considered "downcoding."
If other changes in procedure codes are necessary, such as an "upcode" or change in imaging modality, the provider who renders the service is required to contact eviCore healthcare to amend the PA request. Providers should be aware that PA amendments require approval from eviCore healthcare. Providers are strongly encouraged to obtain approval for a PA amendment prior to rendering services when possible.
Providers are encouraged to review approved PA requests before rendering the service to confirm the procedure code(s) authorized and confirm the assigned grant and expiration dates.
eviCore healthcare notifies the provider who submitted the PA request for advanced imaging services by fax whether a PA request is approved, approved with modifications, or denied. Providers should note that all PA communication is sent via fax from eviCore healthcare. Providers will not receive PA communications for PA requests for advanced imaging services in the mail unless eviCore healthcare is unable to send a fax (for example, fax number is disconnected).
The provider who submitted the PA request receives a PA confirmation fax when a PA request is approved. The PA confirmation fax includes information about the procedure codes that are approved for the member and the grant (effective) and expiration dates for the PA.
The provider who submitted the PA request receives a PA confirmation fax and a PA decision notice letter when a PA request is approved with modifications. Prior authorization decision notice letters are sent via fax.
The provider who submitted the PA request receives a PA decision notice letter via fax when a PA request is denied.
Ordering providers are strongly encouraged to contact the provider who is rendering the service with information about the PA determination. The provider who renders the service is strongly encouraged to verify which services and procedure codes are authorized for the member by using the eviCore healthcare Portal or by contacting the ordering provider prior to rendering services.
The provider who renders the service will not automatically receive separate notification from eviCore healthcare regarding PA approvals, modifications, or denials, except in cases where the provider who renders the service submitted the original PA request.
When a PA request for advanced imaging services is denied, both the provider who submitted the PA request and the member are notified. The provider receives a PA decision notice letter via fax that includes the reason for PA denial. The member receives a Notice of Appeal Rights letter that includes a brief statement of the reason PA was denied and information about their right to a fair hearing. Only the member, or authorized person acting on behalf of the member, can appeal the denial.
Providers may call eviCore healthcare for clarification of why a PA request was denied.
The provider who requested the PA is required to discuss a denied PA request with the member and is encouraged to help the member understand the reason the PA request was denied.
Providers have the following options when a PA request is denied:
If the member does not appeal the decision to deny the PA request or appeals the decision but the decision to deny the PA request is upheld, the member may choose to receive the originally requested service(s) as a noncovered service and to be responsible for payment.
Modification is a change in the services originally requested on a PA request. Modifications include a partial approval (part of the service is approved and part of the service is denied) or the authorization of a procedure code(s) different than the one(s) originally requested.
Prior to modifying the PA request for advanced imaging services to authorize a different procedure code, eviCore healthcare contacts the provider who submitted the PA request by telephone. The provider must agree to the change in procedure code before the PA request can be approved. If the provider does not agree to the change, the PA request is denied.
When a PA request is modified, both the provider who submitted the PA request and the member are notified. The provider will be sent both a PA confirmation fax and a PA decision notice letter via fax that includes the reason the PA was modified. Ordering providers are encouraged to share the information on the PA confirmation fax and the PA decision notice letter with the provider who renders the service. The member receives a Notice of Appeal Rights letter that includes a brief statement of the reason the PA was modified and information on their right to a fair hearing. Only the member, or authorized person acting on behalf of the member, can appeal the modification.
Providers may call eviCore healthcare for clarification of why a PA request was modified.
The provider who requested the PA is required to discuss with the member the reason a PA request was modified and is encouraged to help the member understand the reason the PA request was modified.
Providers have the following options when a PA request is approved with modification:
If the member does not appeal the decision to modify the PA request or appeals the decision but the decision to modify the PA request is upheld, the member may choose to receive the service(s) originally requested as a noncovered service and be responsible for payment.
Providers rendering the service are required to contact eviCore healthcare to amend an approved PA request for advanced imaging services if, based on their medical judgment, it is more appropriate to render a different or more involved service than the one originally approved. Providers are strongly encouraged to request a PA amendment prior to rendering services when possible.
PA amendments will be required in the following circumstances:
The provider rendering the service is not required to contact eviCore healthcare to "downcode" an approved service.
Providers have up to 14 calendar days after the DOS to amend an approved PA request. Amendment requests are subject to additional medical review and may be denied if the PA amendment request is not deemed medically necessary. If the amendment request is denied in this case, the provider cannot request payment from the member since the member was not notified in advance that the service was noncovered.
eviCore healthcare will make a decision regarding a provider's amendment request within 20 business days from the receipt of all necessary information.
The provider who submitted the PA amendment request should request a copy of the PA notification and provide a valid fax number to eviCore healthcare. After adjudicating the PA amendment request, eviCore healthcare will notify the provider by fax whether the PA amendment request was approved, approved with modifications, or denied.
If a PA request is denied or modified by eviCore healthcare, only a member, or authorized person acting on behalf of the member, may file an appeal with the DHA. Decisions that may be appealed include denial or modification of a PA request.
The member is required to file an appeal within 45 days of the date of the Notice of Appeal Rights letter.
To file an appeal, members may complete and submit a Request for Fair Hearing form.
Though providers cannot file an appeal, they are encouraged to remain in contact with the member during the appeal process. Providers may offer the member information necessary to file an appeal and help present their case during a fair hearing.
If the hearing decision upholds the decision to deny or modify a PA request, the DHA notifies the member and ForwardHealth in writing. The member may choose to receive the denied service (or in the case of a modified PA request, the originally requested service) as a noncovered service, not receive the service at all, or appeal the decision.
If the hearing decision overturns the decision to deny or modify the PA request, the DHA notifies ForwardHealth and the member. The letter includes instructions for the provider and for ForwardHealth.
If the DHA letter instructs the provider to submit a claim for the service, the provider should submit the following to ForwardHealth after the service(s) has been performed:
Providers are required to submit claims with hearing decisions to the following address:
ForwardHealth
Specialized Research
Ste 50
313 Blettner Blvd
Madison WI 53784
Claims with hearing decisions sent to any other address may not be processed appropriately.
If the DHA letter instructs the provider to submit a new PA request, the provider is required to submit the new PA request to eviCore healthcare via fax with a copy of the hearing decision. Providers should clearly indicate that the PA request is for a fair hearing decision and should indicate the requested authorization date. If the service has already been performed, the requested authorization date should be the DOS. If the service has not been performed, the requested authorization date should be the earliest date that the service may be performed. eviCore healthcare does not accept PA requests for overturned hearing decisions via telephone or eviCore healthcare Portal.
eviCore healthcare will then approve the PA request for the overturned hearing decision. When a PA request is approved after an appeal, the provider who submitted the PA request receives a PA confirmation fax. Ordering providers are encouraged to share the information on the PA confirmation fax with the provider who rendered or will render the service. The provider rendering the service may then submit a claim following the usual claims submission procedures after providing the service(s).
If the member asks to receive the service before the hearing decision is made, the provider is required to notify the member before rendering the service that the member will be responsible for payment if the decision to deny or modify the PA request is upheld.
If the member accepts responsibility for payment of the service before the hearing decision is made, and if the appeal decision upholds the decision to deny or modify the PA request, the provider may collect payment from the member if certain conditions are met.
If the member accepts responsibility for payment of the service before the hearing decision is made, and if the appeal decision overturns the decision to deny or modify a PA request, the provider may submit a claim to ForwardHealth. If the provider collects payment from the member for the service before the appeal decision is overturned, the provider is required to refund the member for the entire amount of payment received from the member after the provider receives Medicaid's reimbursement.
Wisconsin Medicaid does not directly reimburse members.
If the provider submits a PA request with insufficient clinical data, eviCore healthcare will take the following actions:
If the provider does not respond within 30 calendar days, eviCore healthcare will adjudicate the request based on all available information.
The provider who submitted the PA request may contact eviCore healthcare to request a reconsideration of a denied or modified PA request for advanced imaging services. Reconsideration is an informal review of the denied or modified services conducted by an eviCore healthcare physician consultant. Providers should note that reconsideration is not an appeal. Only a member may appeal a PA determination after a PA request has been denied or modified.
The reconsideration must be requested within 14 calendar days of the PA denial or modification. Reconsiderations requested beyond 14 calendar days will not be processed. To request a reconsideration of a denied or modified PA request, providers should follow these steps:
When a PA request is approved after reconsideration, the provider who submitted the PA request receives a PA confirmation fax. Ordering providers are encouraged to share the information on the PA confirmation fax with the provider who will render the service. It is the responsibility of the provider who submitted the PA request to notify the member if a PA request is approved after reconsideration.
Some covered services consist of sequential treatment steps, meaning more than one office visit or service is required to complete treatment.
In most cases, if a member loses enrollment midway through treatment, or at any time between the grant and end dates, Wisconsin Medicaid will not reimburse services (including prior authorized services) provided during an enrollment lapse. Providers should not assume Wisconsin Medicaid covers completion of services after the member's enrollment has been terminated.
To avoid potential reimbursement problems when a member loses enrollment during treatment, providers should follow these procedures:
Members are financially responsible for any services received after their enrollment has ended. If the member wishes to continue treatment, it is a decision between the provider and the member whether the service should be given and how payment will be made for the service.
To avoid misunderstandings, providers should remind members that they are financially responsible for any continued care after their enrollment ends.
In emergency situations, the PA requirement may be waived for services that normally require PA. Emergency services are defined in Wis. Admin. Code DHS 101.03(52) as "those services which are necessary to prevent the death or serious impairment of the health of the individual."
Reimbursement is not guaranteed for services that normally require PA that are provided in emergency situations. As with all covered services, emergency services must meet all program requirements, including medical necessity, to be reimbursed by Wisconsin Medicaid. For example, reimbursement is contingent on, but not limited to, eligibility of the member, the circumstances of the emergency, and the medical necessity of the services provided.
Wisconsin Medicaid will not reimburse providers for noncovered services provided in any situation, including emergency situations.
eviCore healthcare defines a PA request for a medically urgent situation as any request for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could have the following impact:
For medically urgent situations, providers are encouraged to obtain PA prior to rendering the service when possible. Providers are required to call eviCore healthcare to obtain PA for urgent situations in cases where the service has not yet been rendered. eviCore healthcare will make a PA decision within 72 hours of receipt of all necessary information when the PA request is for an urgent situation. Providers should indicate clearly that the PA is for a medically urgent situation.
Note: eviCore healthcare does not accept PA requests via eviCore healthcare Portal or fax for medically urgent situations in cases where the service has not yet been rendered.
Although providers are encouraged to obtain PA for medically urgent situations prior to rendering the service when possible, eviCore healthcare will allow backdating for PA requests for advanced imaging services for medically urgent situations. Backdating for an urgent situation is allowed up to and including 14 calendar days after the service has been rendered.
A request for backdating may be approved if all of these conditions are met:
PA may be denied if the PA request is received more than 14 calendar days after the DOS, does not meet the criteria for medical necessity, or does not meet the criteria for medically urgent situations. If the PA request is denied in this case, the provider cannot require payment from the member.
Most advanced imaging services, including CT, MR, MRE, and PET imaging, require PA when performed in either outpatient hospital settings or in non-hospital settings (for example, radiology clinics). eviCore healthcare, a private radiology benefits manager, is authorized to administer PA for advanced imaging services on behalf of ForwardHealth. Providers work directly with eviCore healthcare and should submit to eviCore healthcare all information necessary to make a PA determination. eviCore healthcare uses approved national clinical guidelines for imaging services when making PA determinations.
The provider who orders the advanced imaging service (for example, the member's primary care physician, the member's specialist) is required to work with eviCore healthcare to complete and submit the PA request for the service.
The provider or facility that renders the service should do the following prior to rendering the service:
PA requirements apply to advanced imaging services for fee-for-service members enrolled in the following ForwardHealth programs:
PA is also required for members enrolled in state-contracted MCOs who receive physician and radiology services on a fee-for-service basis (for example, Children Come First).
ForwardHealth recommends that providers inform members that PA is required for certain specified services before delivery of the services. Providers should also explain that, if required to obtain PA, they will be submitting member records and information to eviCore healthcare on the member's behalf. Providers are required to keep members informed of the PA request status throughout the entire PA process.
PA is the electronic or written authorization issued by ForwardHealth to a provider prior to the provision of a service. In most cases, providers are required to obtain PA before providing services that require PA. When granted, a PA request is approved for a specific period of time and specifies the type and quantity of service allowed.
Providers are encouraged to set up an account with eviCore healthcare online via the eviCore healthcare Portal. An eviCore healthcare Portal account allows ordering providers and providers who render services to perform the following business functions:
For technical assistance with the eviCore healthcare Portal, providers may contact eviCore healthcare Portal Support by email at portal.support@evicore.com or by phone at 800-646-0418 ext. 20136.
Each PA request for advanced imaging services is assigned a unique PA number by eviCore healthcare. This number identifies valuable information about the PA. The following table provides detailed information about interpreting the PA number.
| Type of Number and Description | Applicable Numbers and Description |
|---|---|
| Media — One digit indicates media type. | PA requests received by eviCore healthcare for advanced imaging services are always identified with media type "9." |
| Year — Two digits indicate the year eviCore healthcare received the PA request. | For example, the year 2010 would appear as 10. |
| Julian date — Three digits indicate the day of the year, by Julian date, that eviCore healthcare received the PA request. | For example, February 3 would appear as 034. |
| Sequence number — Four digits indicate the sequence number. | The sequence number is used internally by eviCore healthcare. |
Only about 4% of all services covered by Wisconsin Medicaid require PA. PA requirements vary for different types of services. Refer to ForwardHealth publications and Wis. Admin. Code ch. DHS 107 for information regarding services that require PA. According to Wis. Admin. Code § DHS 107.02(3)(b), PA is designed to:
PA requests are processed based on criteria established by Wisconsin DHS.
Providers should not request PA for services that do not require PA simply to determine coverage or establish a reimbursement rate for a manually priced procedure code. Also, new technologies or procedures do not necessarily require PA. PA requests for services that do not require PA are typically returned to the provider. Providers having difficulties determining whether or not a service requires PA may call Provider Services.
Wisconsin Medicaid may decline to reimburse a provider for a service that has been prior authorized if one or more of these program requirements are not met:
Providers may not collect payment from a member for a service requiring PA under any of these circumstances:
There are certain situations when a provider may collect payment for services in which PA was denied.
Providers are encouraged, but not required, to request PA from ForwardHealth for covered services that require PA when members have other health insurance coverage. This is to allow payment by Wisconsin Medicaid for the services provided in the event that the other health insurance source denies or recoups payment for the service. If a service is provided before PA is obtained, ForwardHealth will not consider backdating a PA request solely to enable the provider to be reimbursed.
Providers who order advanced imaging services should obtain PA for the services from eviCore healthcare because they likely have the most immediate access to the clinical information necessary to complete the PA request. ForwardHealth allows any provider who can order advanced imaging services within their scope of practice to complete and submit a PA request for advanced imaging services.
eviCore healthcare utilizes evidence-based clinical guidelines derived from national medical associations' recommendations to determine the medical necessity and appropriateness of the requested service(s). The guidelines are published on the eviCore healthcare Portal. eviCore healthcare will make a PA determination based on current ForwardHealth policy in conjunction with the eviCore healthcare guidelines. Providers are reminded that an approved PA does not guarantee reimbursement for the service.
Providers will be required to establish an account on the eviCore healthcare Portal to view the guidelines. Providers without internet access can call eviCore healthcare at 800-575-4517 for a copy of the guidelines on CD.
The provider or facility who renders the advanced imaging service and submits a claim for the service should verify with eviCore healthcare or with the ordering provider that an approved PA is on file for the member prior to rendering the service. Providers can verify PA through the eviCore healthcare Portal or by contacting eviCore healthcare via telephone. If no PA is on file for the member, the provider rendering the services may request the PA prior to rendering the service if the provider can provide eviCore healthcare with the required clinical data. Providers should note that PA information for advanced imaging services will not display on the ForwardHealth Portal. Providers should always refer to eviCore healthcare to verify PA for advanced imaging services.
Providers should have the following member and clinical information on hand when submitting a PA request to eviCore healthcare on the eviCore healthcare Portal, on the telephone, or via fax:
Having complete member and clinical information ready will expedite the PA determination process.
Although providers are encouraged to obtain PA for medically urgent situations prior to rendering the service when possible, eviCore healthcare will allow backdating for PA requests for advanced imaging services for medically urgent situations. Backdating for an urgent situation is allowed up to and including 14 calendar days after the service has been rendered.
A request for backdating may be approved if all of the following conditions are met:
PA may be denied if the PA request is received more than 14 calendar days after the DOS, does not meet the criteria for medical necessity, or does not meet the criteria for medically urgent situations. If the PA request is denied in this case, the provider cannot require payment from the member.
The expiration date (also known as the end date) of an approved PA request is the date through which the approved services are prior authorized. PA requests approved by eviCore healthcare are valid for 60 calendar days from the grant date. eviCore healthcare will not grant requests to extend the authorization period. To extend a PA authorization period, providers are required to submit a new PA request.
The grant date (also known as the start or effective date) of an approved PA request is the first date for which the approved services are prior authorized and may be reimbursed. The grant date for PA requests for advanced imaging services is determined by the date that eviCore healthcare enters the PA request into their system. The grant date is usually the date that the provider submitted the PA request unless the PA request is received after normal business hours. The PA confirmation fax will indicate the grant or effective date of the PA.
Providers may submit PA requests to eviCore healthcare using any of the following methods:
eviCore healthcare is open Monday through Friday, 7 a.m. to 8 p.m. Central time. eviCore healthcare will process PA requests received after hours on the next business day.
Services that are ancillary to an advanced imaging service (for example, contrast agents or sedation) are not subject to PA requirements.
Providers are not required to obtain PA for advanced imaging services separately for different ForwardHealth programs. If a member's enrollment status changes, PA granted for advanced imaging services under one plan will still be valid for the other plan.
In the following situations, PA is not required for advanced imaging services:
Most advanced imaging services, including CT, MR, MRE, and PET imaging, require PA when performed in either outpatient hospital settings or in non-hospital settings (for example, radiology clinics). eviCore healthcare, a private radiology benefits manager, is authorized to administer PA for advanced imaging services on behalf of ForwardHealth. Additional information about PA requirements and submission information for advanced imaging services is available.
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