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Prior Authorization Requests

Utilization Management Team Extends Dates of Service for Approved Prior Authorization Requests

To comply with the Office of the Superintendent of Insurance’s request to minimize prior authorization requirements for COVID-19 testing and treatment, our Utilization Management (UM) team has extended the dates of service for a prior authorization request approved for a service that was delayed or cancelled due to COVID-19.

  • Providers can fax an extension request to the UM team at 1-866-446-3774 or call 1-844-508-4677 to request the extension.
  • Providers don’t need to resubmit all the clinical information for an already approved authorization.

 

How to Obtain Clinical Criteria for Prior Authorization

Providers do not need to submit a prior authorization request, or receive an approval or denial, to obtain clinical review criteria for prior authorization. To obtain clinical criteria for prior authorization, please call 1-844-508-4677.

Which Services Require Prior Authorization?

View a list of healthcare services that do and do not require prior authorization.

The following is a sample of common services that require prior authorization. It includes a list of some of the documents that are required to make a decision about medical necessity.

Physical Therapy, Occupational Therapy, and Speech Therapy

  • Diagnosis
  • Clinical notes
  • Physical exam
  • Treatment plan including goals and progress

 

MRI, CT Imaging

  • Suspected diagnosis
  • Clinical notes
  • Physical exam
  • Plain x-ray report
  • Conservative treatment including medications, physical therapy, and injections (dates and length of treatment)

 

Knee Replacement Surgery

  • Diagnosis
  • Severity and level of pain
  • Physical exam
  • Plain x-ray report
  • Co-morbidities if inpatient stay requested
  • Conservative treatment including medications, physical therapy, and injections (dates and length of treatment)

 

Epidural Spinal Injections

  • Diagnosis
  • Severity and level of pain
  • Physical exam
  • Plain x-ray report
  • Co-morbidities if inpatient stay requested
  • Conservative treatment including medications, prior injections, and response
  • Physical therapy notes

 

Continuous Positive Airway Pressure (CPAP) Therapy

  • Diagnosis
  • Sleep study
  • Adherence report for ongoing treatment
  • Documented improvement with CPAP
Begin a Prior Authorization Request for Services Covered under the Medical Benefit

You may begin prior authorization requests via the Provider Portal or via fax.

  1. Log in to the Provider Portal to start and/or check on the status of your prior authorizations. By logging in, you agree to our Standard Terms of Use.
  2. Download and complete the Prior Authorization Request Form and fax it to 1-866-446-3774. 
Urgent and After-Hours Prior Authorization Requests
  • To submit an urgent after-hours prior authorization request, please call our Customer Care Center at 1-844-508-4677 and follow the prompts to reach the after-hours prior authorization nurse.
  • After-hours requests must be submitted verbally and be urgent in nature. We will process routine prior authorization requests during regular business hours.
Begin a Prior Authorization Request for Services Covered under the Pharmacy Benefit

To begin prior authorizations for pharmacy, please complete the Prior Authorization Request Form and fax it to Pharmacy Services at 1-866-718-7938. Providers may also call 1-866-823-1606 for assistance.

Need Help Submitting Prior Authorizations via Our Provider Portals?
  • Contact the Application Support Team by email at support@evolenthealth.com or by phone at 1-888-959-4031.
  • Identifi Health Plan enhancement: Users now can view authorization requests where the National Provider Identifiers (NPIs) they have access to are listed as the Rendering or Attending provider in addition to Requesting. For details, please view this slide deck.