In addition to managing prior authorizations (PAs) for molecular testing, EviCore completes post-claim reviews for certain molecular testing services for medical necessity on Wellmark’s behalf. These post-service review codes are indicated on the molecular testing code list as “Claim policies apply.”

• Review the lab management code list to determine how EviCore manages each code.
• See the provider resource guide on EviCore claim processing for molecular testing.

Providers may receive medical record requests from EviCore via mail, phone or fax. Providers can submit records via phone or fax using the numbers provided by EviCore.

• The 835 or provider claim remittance will state: “Additional medical information is required to process this claim and has been requested from the appropriate provider. This claim denial may be reconsidered once we receive the requested information.”
• The denial reason code is a 3-digit alpha message starting with “V” (i.e., VER or VEY).

EviCore will NOT review unsolicited medical records.

• Submit medical records via the Wellmark appeal process, if requested.
• Wellmark does NOT require a provider inquiry before a claim appeal for EviCore-related denials.
• Prior to appealing, review the molecular testing guidelines (medical policies) to understand the applicable EviCore claim policy.