Prior authorization for Group Members

Ordering/servicing providers or facilities listed on the request (by NPI) can sign in to Availity to check request status through Availity's Auth/Referral Inquiry tool or dashboard. We typically respond to requests within 1-2 days, but it can take up to 3 days.

To change an existing request, use the following forms, include the reference number, and fax to 800-843-1114. Check our code list for required supporting documentation. 

Fax forms

• General prior authorization request
• Durable medical equipment (DME) request
• Provider-administered infusion drugs request
• Out-of-network pre-authorization and exception request
• Transition of care
• Continuity of care

Definitions

Transition of care

If a member is undergoing treatment, but their current provider isn't in the LifeWise network, they may be able to continue treatment or specific covered services for a limited time with their existing provider.

Continuity of care

 If a member is undergoing treatment, but their current provider is leaving the LifeWise network, they may be able to continue to receive treatment or care for specific covered services for up to 90 days with the existing provider.

Letter of agreement

A contract with an out-of-network facility or provider for specific services for a member. In-network benefits are provided for the services and the member isn't subject to balance billing.

Benefit-level exception

An exception made to allow in-network benefits for services provided at an out-of-network facility or by an out-of-network provider. The member is still subject to balance billing.

Medical services

• Advanced imaging, radiation oncology, sleep disorder management, and genetic testing: Visit Carelon Medical Benefits Management (formerly AIM) or call 866-666-0776
• Outpatient rehabilitation: Visit eviCore healthcare
• Prescription drug/provider/covered-drugs prior authorization: Find our drug lists
• Inpatient admission notification: Visit our admission notification page

Outpatient rehabilitation codes 

Check our code list to view outpatient rehabilitation codes. If no results are found, the code doesn't require review. We review non-specific codes when the claim is submitted. 

More information

To create an account and/or initiate an authorization:

• Visit eviCore healthcare
• Call 800-792-8751 from 7 a.m. to 7 p.m., Monday through Friday (out-of-network providers: submit requests by calling this number.)
• Fax an eviCore healthcare request form to 800-540-2406 
  (Go to Online Forms & Resources to select the specific treatment form.)

Visit eviCore healthcare for: 

• Orientation, training, tutorials
• Clinical guidelines and worksheets
• CPT code list
• Medical necessity review authorization request (available through the clinical certification online tool)
• Performance summary reports (sign in and select PPS in top navigation)

eviCore healthcare is an independent company managing outpatient rehabilitation services for LifeWise providers.

We know situations can happen that may make it impossible to get prior authorization before treating a patient, or to notify us within 24 hours of admission. If a patient’s emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.

In these situations, contact us before submitting a claim. Follow the recommended practices outlined in the extenuating circumstances policy so that the claim isn't automatically denied.

Carelon Medical Benefits Management (formerly AIM Specialty Health) manages prior authorization for select services for LifeWise. Prior authorization is required for certain procedures and services. Contracted providers are financially liable for providing services that are medically unnecessary. Providers must make prior authorization requests through Carelon for members on plans that require it. 

Prior authorization is based on member benefits and eligibility at the time of service. It determines medical necessity, treatment appropriateness, and setting via nationally recognized guidelines. 

The following services are subject to review by Carelon:  

• Genetic testing 
• Imaging (CT scan, echocardiography, MRI, MRA, nuclear cardiology, PET scan) 
• Radiation oncology 
• Sleep study 

View the code list to see which codes require review.

View Carelon Clinical Appropriateness Guidelines.

To request a prior authorization, register with Carelon and then submit your request online or by phone at 866-666-0776.

Prior authorization isn't required for the following:

• Emergency room services
• Inpatient hospitalization
• Observation stays

Servicing providers are strongly encouraged to verify that the prior authorization has been received before scheduling and performing services. In addition, servicing providers must submit ordering/referring provider information, per guidelines from the Centers for Medicare and Medicaid Services (CMS), in boxes 17 and 17b on CMS-1500 forms.

If you have questions, call Carelon at 866-666-0776.

Carelon resources for providers

• Genetic testing program
• Radiology
• Radiation oncology
• Sleep study program

Carelon Medical Benefits Management is an independent company providing select services to LifeWise Health Plan of Washington providers.