Reminder: eviCore to Manage Commercial Prior Authorization Appeals Process through April 2021 for 2020 Adverse Determinations
As a reminder, for dates of service on or after Jan. 1, 2021, AIM Specialty Health is the utilization management vendor for Blue Cross and Blue Shield of Oklahoma (BCBSOK) commercial Prior Authorization (PA) requests that were formerly handled by eviCore Healthcare®. To assist providers with this transition, in December 2020, a notice appeared on the eviCore website to alert providers of the appeals run-out process, which will continue through April 2021.
If eviCore has denied a PA (pre-service) request or conducted a post-service (post-claim) medical necessity review resulting in an adverse determination, peer-to-peer discussions and appeals must be requested through eviCore. For these pre- and post-service adverse determinations for 2020 dates of service and prior, eviCore will continue to process peer-to-peer and appeal requests through April 30, 2021, only. After April 30, 2021 any peer-to-peer and appeal requests for 2020 dates of service and prior should be submitted to BCBSOK.
The vendor that issued the pre- or post-service adverse determination will process any related peer-to-peer or appeals requests through April 30, 2021. For any adverse determination after Jan. 1, 2021, follow the instructions in the letter you receive from BCBSOK.
Check eligibility and benefits through Availity® or your preferred vendor, to:
- Determine whether prior authorization is required
- Confirm benefit coverage
- Determine which vendor to use for prior authorization
Checking eligibility and/or benefit information 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, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSOK.
AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSOK.
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSOK.
Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association