New Prior Authorization Requirements for Medical Specialty Drugs Under 1199SEIU

02/10/2025

New Prior Authorization Requirements for Medical Specialty Drugs Under 1199SEIU

To streamline the management of medical specialty drug benefits for 1199SEIU patients, the 1199SEIU Benefit Funds ("Funds") are implementing changes to their prior authorization process. Effective Mar. 1, 2025, the Funds will transition the Medical Specialty Drug Prior Authorization Program to EviCore, replacing the current management by CareContinuum.

What This Means for Providers

EviCore will be responsible for reviewing and approving prior authorization requests for select medical specialty drugs that are purchased, billed, and administered in outpatient settings, as well as gene therapies provided in inpatient settings. This review will also include an assessment of the appropriateness of the units billed.

How to Request Prior Authorization

Starting Mar. 1, 2025, providers must submit prior authorization requests for medical specialty drugs through the EviCore provider portal. This portal should also be used for retrospective reviews or appeals of previously administered services. Additionally, providers may contact EviCore through:

Phone: (844) 840-1199
Fax: (800) 540-2406

To prevent claim denials and payment delays, it is essential to obtain authorization before administering medical specialty drugs to 1199SEIU patients. Services performed without prior authorization cannot be billed to the patient.

When to Request Prior Authorization

Providers should submit prior authorization requests before scheduling the service and ensure that the rendering facility receives the approval information. Each authorization will include a unique approval number and one or more CPT codes specific to the approved services. If the treatment plan changes, the rendering facility must update the authorization with EviCore before submitting claims.

For medically urgent cases requiring treatment within 48 hours, providers must:

Submit an expedited request through EviCore’s website and indicate that the procedure is urgent.
Call EviCore at (844) 840-1199 and inform the representative that the request is for medically urgent care.

Services That Do Not Require Prior Authorization

While prior authorization is mandatory for most specialty drugs, certain exceptions apply:

Gene therapies and specialty drugs requiring inpatient hospital stays still require prior authorization.
No prior authorization is required for services performed as part of:
An inpatient hospital stay (except for gene therapies and specific inpatient-required treatments)
A 23-hour observation period
An emergency department visit

Providers should take note of these updates to ensure compliance and avoid unnecessary claim denials. For additional details, visit the EviCore provider portal or contact EviCore directly.

Source: 1199SEIU Benefit Funds