New Medicare Prior Authorization Requirements through eviCore

February 8, 2017

Updated April 13, 2017

Blue Cross Medicare AdvantageSM has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide Utilization Management services for prior authorization requirements outlined below.

Effective June 1, 2017, Blue Cross Medicare Advantage members will be subject to the prior authorization requirements set forth in this article. eviCore will manage prior authorization requests for the following specialized clinical services effective for dates of service on or after June 1, 2017:

  • Outpatient Molecular Genetics
  • Outpatient Radiation Therapy
  • Musculoskeletal
    • Chiropractic
    • Physical and Occupational Therapy
    • Speech Therapy
    • Spine Surgery (Outpatient/Inpatient)
    • Spine Lumbar Fusion (Outpatient/Inpatient)
    • Interventional Pain
  • Outpatient Cardiology & Radiology
    • Abdomen Imaging
    • Cardiac Imaging
    • Chest Imaging
    • Head Imaging
    • Musculoskeletal
    • Neck Imaging
    • Obstetrical Ultrasound Imaging
    • Oncology Imaging
    • Pelvis Imaging
    • Peripheral Nerve Disorders (Pnd) Imaging
    • Peripheral Vascular Disease (Pvd) Imaging
    • Spine Imaging
  • Outpatient Medical Oncology
  • Outpatient Sleep Program
  • Outpatient Specialty Drug

The Blue Cross Medicare Advantage Preauthorization Requirements List PDF Document has been updated to include the services listed above that require preauthorization through eviCore, for dates of service on or after June 1, 2017.

Beginning May 22, 2017 providers can contact eviCore using one of the following methods:

  • The eviCore HealthCare Web Portal Learn more about third-party links will be available 24x7. After a one-time registration, you are able to initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
  • Providers can call toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday.

The rendering provider must obtain prior authorization for services outlined in this notification, except for emergency care or urgent services. PCP referrals are not required if the specialty provider selected is in network.

Services performed without prior authorization and that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

iExchange® services will continue to be available for all other services that require prior authorization.

BCBSOK and eviCore will be providing additional information, including training opportunities, in the coming months. Please continue to visit the site and the BCBSOK Blue Review Newsletter for updates.

Please note that the fact that a service has been preauthorized/pre-certified 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.

* eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSOK.

** Prior authorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Prior authorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.