Authorization Grids

Effective 10/1/2017, for all product lines of business except Fidelis Care at Home (FCAH) and Fully Integrated Duals Advantage (FIDA), prior authorization is required through eviCore healthcare (eviCore) for Outpatient High-tech Radiology, Non-obstetrical Ultrasounds, Diagnostic Cardiology, and Radiation Therapy. Starting 9/20/2017, requests for services performed on or after 10/1/2017 can be submitted to eviCore by:

Web Portal: and click on 'Providers' to login
Fax: 1-800-540-2406
Phone: Call eviCore toll-free at 1-866-706-2108, Monday through Friday, from 7 AM to 7 PM in all time zones

Authorization Grids are now available for Medicare, Medicaid, Child Health Plus, NY State of Health Marketplace plans, and Fully Integrated Duals Advantage (FIDA) and are effective for dates of service occurring on or after the dates below.

Medicaid, Child Health Plus, and HealthierLife (HARP)


Metal-Level Products

Essential Plan