What to do before you submit—and if you’re denied—to support a successful prior authorization request

One of the most effective ways to ensure a smooth prior authorization process is to verify that all required documentation is attached before submitting. And if a denial does occur, there are several steps available before filing a formal appeal. Here’s what to know:

Before submitting a prior authorization request

1. Review EviCore’s Clinical Guidelines

Confirm that the requested service aligns with the criteria outlined in EviCore’s Clinical Guidelines. Reviewing these first helps set accurate expectations and supports a stronger submission.

2. Download and use the Required Medical Information Check List

Use EviCore’s Required Medical Information Check List to confirm all necessary clinical documents and details are included. This check list is designed to help you catch any gaps before submission.

3. Withdraw the request if documentation is not yet available

If supporting documentation isn’t ready, consider withdrawing the request and resubmitting once everything is in hand. This simple step can help you avoid a preventable denial.

If your request was denied for missing clinical information

If a prior authorization request was determined not medically necessary due to incomplete clinical documentation, several post-decision options may be available before filing a formal appeal.

1. Review your determination letter

Start here. The letter outlines the reason for the denial and the next-step options available to you.

2. Submit a reconsideration (when available, as noted in your determination letter)

Reconsideration allows you to provide missing or additional clinical information for review without the need to schedule a peer-to-peer discussion.

3. Request a peer-to-peer discussion

If needed, you may speak directly with a clinical reviewer to discuss the denial and present additional clinical context.

4. Submit an appeal (final option)

If other pathways are not available or do not resolve the issue, a formal appeal can be filed.