Prior Authorization : Follow-Up to Decisions

Reconsideration Requests

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:

• Call eviCore healthcare.
• eviCore healthcare schedules a telephone conversation (a "peer-to-peer review") with either the eviCore healthcare physician consultant on duty or the physician consultant who made the PA determination. The provider should specify if they want to talk to the physician consultant who made the PA determination.
• During the peer-to-peer review, the eviCore healthcare physician consultant may either reverse the decision based on additional clinical information and approve the PA request or the consultant may uphold the original decision to deny or modify the PA request.

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.