Advanced diagnostic imaging auth approval process

Imaging facilities need an authorization prior to performing any high-tech radiology service on a patient in order to be reimbursed.

The approval process for high-tech radiology authorization requests

1. The physician uses the Auth Request tool or calls eviCore healthcare at 844.303.8456 to make an authorization request, documenting the medical necessity of the requested service. View required information.
2. A referral specialist receives the request and all pertinent clinical information related to the request.
3. Medical necessity review:

   The referral specialist may approve the request immediately or refer it to a Registered Nurse for review;

   The nurse may approve it or refer it to a physician reviewer;

   The physician reviewer may approve it or discuss it with a clinician at the requesting provider's office.

   The request cannot be denied by anyone other than a physician reviewer, or without discussion with the requesting provider.

4. Approval or denial:

   eviCore faxes the requesting and servicing providers and sends a letter to the member, with either a denial or an authorization number. The authorization number begins with an alpha character followed by nine numbers: A123456789, for example. The authorization number is followed by the CPT code for the procedure authorized.

   No notification is sent to the rendering facility.

   Requests that do not meet medical necessity criteria will be denied.

• For commercial policies: Do not send appeals to Priority Health. Services authorized by eviCore must be appealed through eviCore within 120 days of service date.
• For governmental policies: Send appeals to Priority Health.