Effective March 1, 2025, the 1199SEIU Benefit Funds will leverage its partnership with EviCore to manage the Funds’ Medical Specialty Drug Prior Authorization Program. EviCore will perform prior authorizations for certain medical drugs that are bought, billed and administered in an outpatient setting or gene therapies in an inpatient setting. Starting March 1, 2025, all providers must contact EviCore for prior authorization before administering these specialty drugs to their 1199SEIU patients.

In addition to prior authorization, EviCore will review all medical specialty drug procedure claims for coding accuracy and medical necessity. Refer to the procedure category and CPT/HCPCS code range on the Medical Specialty Drug List. We urge you to update your claims submission systems and coding practices accordingly to avoid payment delays or unnecessary denials.

Effective March 1, 2025, EviCore manages the 1199SEIU Benefit Funds’ Medical Specialty Drug Prior Authorization Program. EviCore performs prior authorizations for certain medical drugs that are bought, billed and administered in an outpatient setting or gene therapies in an inpatient setting. Providers must contact EviCore for prior authorization before administering specialty drugs to their 1199SEIU patients.

In addition to prior authorization, EviCore reviews all medical specialty drug procedure claims for coding accuracy and medical necessity. Refer to the procedure category and CPT/HCPCS code range on the Medical Specialty Drug List. We urge you to update your claims submission systems and coding practices accordingly to avoid payment delays or unnecessary denials.

If you receive an adverse payment decision as a result of EviCore’s code policies, you may submit a request for claim review directly to EviCore. You should fax requests to (844) 545-9214 or mail requests to EviCore healthcare, 400 Buckwalter Place Blvd., Bluffton, SC 29910. Include a copy of the claim, EviCore correspondence, information about the determination to be reviewed and any pertinent documentation to support your request for claim review.

How to Request Prior Authorization for Medical Specialty Drugs Non-oncology Services

• Online: If you have an EviCore provider account, or once you create one for free, visit EviCore's website and log in. You may be able to receive an immediate authorization if your patient meets the coverage criteria.
• By phone: Call EviCore toll-free at (888) 910-1199, Monday through Friday, from 7:00 am to 7:00 pm in all time zones.
• For urgent requests: If services are required in less than 48 hours due to medically urgent conditions, please call EviCore toll-free at (888) 910-1199 for expedited authorization reviews. Be sure to tell the EviCore representative that the authorization is for medically urgent care.

Note: EviCore will not accept initial authorization requests by fax.

If you have any questions about this program, please contact your provider representative or visit the EviCore 1199SEIU Funds Implementation Resources page.

Orientation

The orientation will include detailed information about the prior authorization process and how to access information from the EviCore website, as well as a question-and-answer period. Online orientation is offered multiple times, so register for the date and time that work best for you. Each session will last approximately one hour. There is no additional cost for orientation, but registration is required.

Orientation is offered on the following dates:

• Tuesday, February 18, 11:00 am
• Wednesday, February 19, 11:00 am
• Tuesday, March 4, 11:00 am
• Wednesday, March 5, 10:00 am

How to register:

1. Visit the EviCore–WebEx registration portal.
2. Select “WebEx Training” from the menu bar on the left.
3. Click the “Upcoming” tab. Choose “1199SIEU Medical Specialty Drug Provider Orientation Invitation.” (Note: You may have to scroll down or advance to the next page of results to find the right orientation.)
4. Click “Register” next to the session you wish to attend.
5. Enter your registration information.

After you have registered, you will receive a confirmation email containing everything you need to join the session: the toll-free call-in number, meeting number, conference password and link to the online orientation. Please keep the confirmation email so you’re able to easily join the session.

If you are unable to participate in a session, or if you want to refer back to what you learned, we encourage you to view a copy of the presentation, as well as other important documents, on the EviCore website. (All documents are available in PDF format.)

Please direct your questions about joining the session or using the EviCore web portal to EviCore’s Web Support team at [email protected] or (800) 646-0418, option 2. For other questions, please email [email protected].

Additional Resources

• EviCore Specialty Drug Quick Reference Guide »
  A one-page guide with useful information, including how to submit a prior authorization request and key contacts.
• Medical Specialty Drug Prior Authorization Program FAQs »