Evicore musculoskeletal authorization form

Cigna works with eviCore healthcare to administer a precertification program for Cigna customers for certain musculoskeletal services (e.g., interventional pain management and major joint surgery procedures) for outpatient and inpatient services. The following information outlines the highlights of this relationship.

Delegated Services

eviCore is delegated for the following services:

• Utilization management, including precertification
• Clinical appeals

Precertification

Our precertification program helps ensure that individuals help receive cost-effective care that is covered on established evidence-based guidelines.

Precertification is required for:

• All Cigna customers receiving these services in the inpatient setting
• Cigna customers receiving these services in the outpatient setting and whose Cigna ID card identifies that precertification is required for outpatient procedures.

For these customers, eviCore performs precertification for major joint surgery services related to the hip, knee and shoulder as well as for interventional pain management as part of this program.
For a full list of CPT codes included in this program (and that require precertification to be requested through eviCore), please go to https://www.evicore.com/Cigna

How to request precertification

Providers can request precertification in of three dedicated ways:

• Website: eviCore.com
• Phone: 888.693.3297
  (8:00 am - 9:00 pm EST)
• Fax: 888-693-3210

To request precertification for urgent requests, providers must call eviCore at 888.693.3297.

Important notes

• It is the responsibility of the performing facility or provider to confirm recertification has been requested and approved prior to service(s) being performed.
• Once all clinical information is received for non-urgent precertification requests:
  • Decisions are typically made within two business days. All decisions are made within five business days.

  Precertification for urgent services

  • When musculoskeletal services are required in less than 48 hours due to a medically urgent condition, the ordering provider must call eviCore for precertification approval.
  • Urgent treatment requests can only be made by phone. *
  • The provider must clearly indicate that the treatment is for medically urgent care.
  • Once all necessary information is received, eviCore will make a decision within 24 hours.
  * Requests received by fax or online will be treated as standard cases

  Tools and Resources

  Please visit https://www.evicore.com/Cigna for helpful information on the below topics:

  • Utilization Management/Precertification
  • Quarterly Provider Newsletters
  • Clinical Quick Reference Guide
  • Frequently Asked Questions

  Value to providers and customers

  Applying evidence-based clinical guidelines helps to focus on guiding the physician in delivering medically necessary care that is safe and effective to customers.

  • eviCore's case determination software platform supports providers by conducting an individualized evidence-based care analysis tailored to the customer's condition.
  • eviCore's unique education approach includes the only "predictive intelligence" technology in the industry, which provides nearly instant precertification approval in areas where a physician consistently practices within our evidence-based guidelines.
  • Providers have access to licensed, board-certified clinicians to assist in a consideration of musculoskeletal service options. These clinicians have the same specialty expertise and the treating physician.
  • eviCore supports the intent of Choosing Wisely ® , which is an initiative of the ABIM Foundation (choosingwisely.org) that helps physicians and patients engage in conversations to reduce overuse of tests and procedures, while supporting physician efforts to help patients make smart and effective health care choices.

  Contact Information

  Clinical Support

  eviCore welcomes requests for clinical discussion from rendering providers. One of eviCore's physicians can assist in a consideration of interventional pain and joint surgery options. To request a clinical discussion, call eviCore at 888.693.3297 option four.

  Submitting claims

  All providers should submit claims directly to Cigna at the address in the back of the patient's Cigna ID card.

  Submitting clinical appeals

  Providers should refer to the denial notification for instructions on where to submit appeals.

  Dedicated website support

  Contact the eviCore website support team by:

  • Phone: 800.575.4594 (8:00 am - 9:00 pm EST)
  • Email: portal.support@evicore.com
  • Online: Click on "Online Chat" located in the upper right hand corner of each page at evicore.com