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, HealthierLife (HARP), Metal-Level Products, and the Essential Plan 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