Prior Authorization : Follow-Up to Decisions

Amendments

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 renders a service with contrast when the approved service did not include contrast (i.e., "upcodes"). For example, the provider renders a service indicated by procedure code 70460 (Computed tomography, head or brain; with contrast material[s]) when the PA confirmation fax authorized procedure code 70450 (Computed tomography, head or brain; without contrast material).
• The provider renders a service with scans both with and without contrast when the approved services did not include contrast or only included scans with contrast (i.e., "upcodes"). For example, the provider renders a service indicated by procedure code 70470 (Computed tomography, head or brain; without contrast material, followed by contrast material[s] and further sections) when the PA confirmation fax authorized procedure code 70450 (Computed tomography, head or brain; without contrast material) or 70460 (Computed tomography, head or brain; with contrast material[s]).
• The provider images a different body part than originally approved. For example, the PA confirmation fax authorized procedure code 72192 (Computed tomography, pelvis; without contrast material) but the provider renders a service indicated by procedure code 72131 (Computed tomography, lumbar spine; without contrast material).
• The provider uses a different imaging modality than originally approved. For example, the PA confirmation fax authorized procedure code 70450 (Computed tomography, head or brain; without contrast material) but the provider renders a service indicated by procedure code 70551 (Magnetic resonance [eg, proton] imaging, brain [including brain stem]; without contrast material).

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.