eviCore healthcare (eviCore) manages utilization of our inpatient and outpatient spinal surgeries. All spinal surgery codes indicated on our Commercial Pre-authorization List and Medicare Advantage Pre-authorization List in the Physical Medicine section for Spine require pre-authorization through eviCore for all members listed as included in the program.
Note: Spinal procedure/surgery pre-authorization requirements as noted on our pre-authorization lists remain in effect as published for administrative services only (ASO) groups listed as they are excluded from this program.
Failure to secure authorization approval for these services will result in claim non-payment and provider write-off.
Post-service, prepayment claims review
All spine surgery procedure claims authorized through eviCore from providers and facilities are reviewed as part of a post-service, prepayment claims review. As part of this claims review:
- eviCore may contact the provider or facility directly by fax to request documents that include, but are not limited to, operative notes, clinical medical records, and/or itemized bills/invoices to process claims.
- If you receive a request from eviCore, please submit the information within the required 45 days indicated in the request. Failure to submit the requested information within that time frame may result in a complete claim denial.