Recently we have seen an increase in precertification denials for services requested through our delegated vendors who complete reviews for our utilization management programs:
- AIM Specialty Health® (AIM), an independent company
- Cardiology Utilization Management Program
- Musculoskeletal Utilization Management Program
- certain outpatient nonemergent diagnostic imaging services
- sleep studies
- CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent specialty benefit management company
- genetic/genomic tests, certain molecular analyses, and cytogenetic tests
- radiation therapy
Providers are not submitting the necessary clinical information with the initial precertification request causing processing delays and denials due to lack of information supporting medical necessity.
It is important that providers submit
allnecessary information through the initial Authorizations Workflows menu on the NaviNet® web portal (NaviNet Open) or directly to AIM or eviCore to avoid precertification denials and unnecessary delays in decision making and developing treatment plans for your patients.
Review the questions below for more information:
|
Question |
AIM |
eviCore |
|---|
How will providers know if they submitted incomplete information for a precertification request? | AIM will attempt outreach to the provider through the contact information provided in the request. If they are unable to reach the provider for additional information, the request will be denied and then closed. For Medicare Advantage requests, there are three outreach attempts: (i) when an AIM Referral Specialist offers a peer-to-peer review call or through peer-to-peer messaging on the Portal; (ii) the case review outreach by fax; and (iii) verbal pending denial outreach. The verbal pending denial outreach for Medicare Advantage cases occurs while the review is still open. For commercial reviews, AIM offers a peer-to-peer review call or through peer-to-peer messaging on the Portal. Once the review is closed, AIM will notify the provider of the review determination. | eviCore will fax the pending authorization and make three outreach attempts to the provider through the contact information provided in the request. |
Can providers see if they need to submit additional information through the AIM or eviCore provider portals? | Providers are only able to see that additional information is required. | Providers will be issued a “pending” authorization letter stating that additional information is required. |
How long will a precertification request remain open with pending information? | AIM will keep the request open within the following time frames from the initial date of submission: -
Commercial
-
Standard: Three business days
-
Urgent: 72 hours
-
Medicare Advantage
-
Standard: 14 calendar days
-
Urgent: 72 hours
| Providers have ten calendar days to submit additional information. A final determination will be made two business days after the receipt of additional information. |
If the precertification request is denied, will a new precertification request be required when additional information is submitted? |
Yes. If the initial request is denied due to insufficient information, a new precertification request will need to be submitted. |
Yes. If the initial request is denied due to insufficient information, a new a precertification request will need to be submitted. |
Learn more
If you have questions related to services in our utilization programs that require precertification, visit our dedicated web pages for AIM and eviCore.
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