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  • Evicore Healthcare Pt/ot Treatment Request For Clinical Worksheet Musculoskeletal Conditions

Get Evicore Healthcare Pt/ot Treatment Request For Clinical Worksheet Musculoskeletal Conditions

PT/OT Treatment Request Clinical Worksheet Musculoskeletal Conditions Ordering Provider Patient/Member For NONURGENT requests, please fax this completed document along with medical records, imaging,.

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Option 1: Peer-to-Peer Discussion Suppose you want an additional review of the initial request. In that case, you can ask your healthcare provider to set up a peer-to-peer discussion with one of EviCore's medical directors, who will be from your provider's specialty.

Please submit authorization forms via fax at 1-844-965-9053 or call 1-855-672-2755.

To request an authorization: Call EviCore at 1-888-693-3211.

If the level of review is an appeal you will receive a determination within the standard 30 days, or earlier based on state or federal requirements, as defined in the appeal rights of the initial decision notice. If you do not hear from EviCore within the standard 30 days, please call 800-792-8744, option 4.

1. Claims must be received by eviCore healthcare within 120 calendar days of the date of service.

Aetna has contracted with eviCore healthcare, an independent specialty medical benefits management company, to administer prior authorization for Enhanced Clinical Review program. Authorization May Be Required. • CT scans (including CTA) • MRI/MRA. • PET Scans.

The quickest, most efficient way to obtain prior authorization is through the 24/7 self-service web portal at .evicore.com. Prior authorization can also be obtained via telephone at 1-888-693- 3211 or fax at 1-888-693-3210.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232