eviCore Process Reminder for Commercial PPO Benefit Preauthorization Requests

Posted June 20, 2019

Benefit preauthorization through eviCore healthcare (eviCore) may be required prior to rendering select outpatient procedures for some of our Commercial PPO members. As a reminder, for these members, if eviCore receives a benefit preauthorization request with no or insufficient clinical information to confirm medical necessity, the case may be pended (placed on hold) for up to five business days.

If a request is pended, the provider will receive a faxed letter from eviCore that specifies what information is required, the deadline for submission and instruction on how to submit the missing information. A letter will be mailed to the member, explaining that eviCore has contacted the provider for more information.

If eviCore does not receive a response from the provider within the allotted time frame, the case will be reviewed, and the services may be reduced or denied. Also, if clinical information is received, and medical necessity is not confirmed, services may be reduced or denied.

Quick Tips to Help Avoid Delays in Case Processing

  • Submit benefit preauthorization requests electronically through eviCore’s provider portal. Cases may be eligible for review in real-time. If not, clinical notes may be uploaded with your request.
  • Use the worksheets on eviCore’s Provider Resource Page. These worksheets define required clinical information.
  • Make sure that all information provided is current and complete.
  • If needed, contact eviCore at 855-252-1117 to discuss the case with a physician advisor.

For eviCore provider portal help, email or call 800-646-0418 and select option 2. Benefit preauthorization requests also may be submitted by calling eviCore at 855-252-1117, Monday through Friday, from 7 a.m. to 7 p.m. If you have questions, email or call 800-646-0418 (option 4).

Always Check Eligibility and Benefits First 

Benefits will vary based on the service being rendered and individual and group policy elections. It’s critical to check eligibility and benefits for each patient to confirm coverage details. This step will also identify benefit preauthorization/pre-notification requirements and specify utilization management vendors that must be used, if applicable. Submit online eligibility and benefits requests (electronic 270 transactions) via the Availity® Provider Portal or your preferred web vendor portal.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized/pre-notified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, call the number on the member’s ID card.

eviCore is an independent specialty medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Illinois (BCBSIL). Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore or Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.