Radiology: Advanced diagnostic

Applies to:

All plans except Medigap (Medicare supplement insurance) and in other situational exceptions below.

Medicare plans follow Medicare coverage rules.

Out-of-network providers:

Request authorization for high-tech radiology services by completing the Medical Prior Authorization form. Authorizations aren't available over the phone, but if you have questions, call the Provider Helpline. Choose the "authorization" option.

Participating providers:

  • Request prior authorization for most Priority Health patients through the Auth Request online tool before ordering advanced diagnostic imaging studies and exams. See "Advanced diagnostic imaging authorization request process," below.
  • Servicing providers should log in to eviCore using our Auth Request tool before services are performed to confirm that an authorization number for the patient, test and date range has been approved.

Authorization is required for:

  • CT/CTA

  • MRI

  • MRA

  • Nuclear cardiac studies

  • PET scans

Exceptions to the requirement for prior authorization:

  • Emergency department or urgent care facility
  • Services related to same-day outpatient surgeries
  • Inpatient stays
  • Observation
  • Priority Health "Medigap" Medicare Supplement insurance patients
  • Gentex (group 783589) patients

Advanced diagnostic imaging prior authorization request process

Here's how to submit the required information to receive an authorization number.

  • Recommended: Use the Auth Request tool 24 hours a day, 7 days a week*.
    • You'll be taken to eviCore healthcare to complete your auth request.
    • Requests may be approved in real time and authorization numbers provided immediately.
    OR
  • Call eviCore toll-free at 844.303.8456, Monday through Friday, 7 a.m. to 7 p.m. Eastern Time.

*Note: eviCore is closed on Jan. 1, Memorial Day, July 4, Labor Day, Thanksgiving and the Friday after, and Christmas day.

Urgent requests

Call eviCore at 844.303.8456. Outside business hours, leave a message. Urgent cases will be reviewed within 24 hours for Medicare and Medicaid/Healthy Michigan Plan members and within 72 hours for commercial group and individual members.

Changes and add-on procedure requests

To request add-on procedures or make changes to an existing authorization, call eviCore at 844.303.8456. If you have all clinical details available and your existing authorization number, eviCore may be able to approve the changes/add-on request immediately. Otherwise, it will pend for review. These requests can only be made by the ordering provider.

Retrospective requests

See retrospective authorization instructions.

More information about the prior authorization process

  • Information required in an authorization request
  • Steps of the authorization review process

Appealing a decision

Appeals must be in writing unless the request is for urgent care, in which case the request may be made by phone. Appeal rights are detailed in the coverage determination letter sent with an authorization denial. eviCore will manage only Level 1 provider appeals for commercial group and individual plans.

Resources available at the eviCore website