Prior Authorization : General Information

Requesting Prior Authorization

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.

Information Required When Requesting PA

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:

• The member's full name, date of birth, and address
• The member's ForwardHealth member ID number
• The member's working or differential diagnosis
• Prior tests, lab work, and/or imaging performed related to the member's diagnosis
• Type and duration of treatment performed to date for the diagnosis
• Requested imaging service (e.g., "MRI of the brain") or requested procedure code if known (Note: PA requests for advanced imaging services do not require modifiers even if the procedure code is billed with a modifier.)
• A Medicaid-enrolled rendering facility (Note: Members may choose a different Medicaid-enrolled rendering facility than the one submitted to eviCore healthcare with the PA request. Amendments to the PA request are not required for a change in the rendering facility.)

Having complete member and clinical information ready will expedite the PA determination process.