Prior authorization will be required for the following services:
Outpatient high-tech Radiology services
Outpatient Non-Obstetrical Ultrasounds
Outpatient diagnostic Cardiology services
Outpatient Radiation Therapy services
For a full list of the procedure codes, visit: eviCore Healthcare
No Authorization Required
Prior authorization will not be required for radiology services performed:
During an Inpatient stay
During an Observation stay
In the Emergency Room
Non-Obstetrical Ultrasounds which are utilized for guidance purposes during a procedure
Products Included in Program
Medicaid Managed Care (MMC)
Child Health Plus (CHP)
Medicare Advantage (MA)
Dual Advantage (DUAL)
Medicaid Advantage Plus (MAP)
Metal-Level Products (Qualified Health Plan)
Essential Plan (EP)
HealthierLife (HARP)
Products Not Included in Program
Fidelis Care at Home (FCAH) / (managed long-term care)
Fully Integrated Duals Advantage (FIDA)
Requesting an Authorization
Beginning September 20, 2017, all authorization requests for services under this program, being performed on or after October 1, 2017, should be submitted directly to eviCore. Authorizations can be submitted through the eviCore web portal, by phone, or by fax.
For further details regarding this new prior authorization program, please visit Fidelis Care or refer to Provider Tip Sheet: eviCore Program (includes FAQs).
If you have additional questions please contact your account representative at WCH.
