Evicore treatment request 2026

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The document is a clinical worksheet for requesting physical therapy (PT) and occupational therapy (OT) treatments for patients with musculoskeletal conditions. It outlines the necessary information to be provided by the ordering provider, including patient details, diagnosis, treatment history, and specific clinical findings. The form emphasizes the importance of completeness to avoid delays in authorization and includes sections for documenting range of motion, strength measurements, pain levels, and functional assessments.

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Click ‘Get Form’ to open the evicore treatment request in the editor.
Begin by filling out the 'Ordering Provider' section, including your first name, last name, and contact information. Ensure accuracy to avoid delays.
Next, complete the 'Patient/Member' section with the patient's details such as DOB, gender, and address. This information is crucial for processing.
In the 'Diagnosis' section, specify the primary area being treated and any relevant ICD-10 codes. If applicable, indicate if this is a new condition or ongoing care.
Proceed to fill out clinical information regarding range of motion (ROM) and strength measurements. Be thorough in documenting any abnormalities.
Finally, review all entries for completeness and accuracy before submitting. Use our platform's features to save your progress or make edits as needed.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I type my eSignature on my 1 800 792 8744?

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How do you complete evicore appeal form online?

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What is the phone number for eviCore prior authorization?

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

What is eviCore authorization?

The prior authorization process uses evidence-based clinical guidelines to ensure that every health plan member receives the most appropriate care while avoiding unnecessary exposure to potentially harmful substances, as well as additional costs.

What does eviCore handle?

eviCore works with health plans to help their members like you avoid unnecessary care that is costly and potentially unsafe. We do that by applying the latest evidence-based medical guidelines through a process sometimes referred to as prior authorization.

evicore clinical worksheet

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How do I appeal eviCore denial?

Information regarding appeal options, and with whom an appeal should be filed, can be found in the determination letter. You can also contact eviCore healthcare via the telephone number provided on the determination letter, to understand what appeal options are available at the time of your inquiry.

What is the phone number for eviCore appeal?

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.

Is eviCore a Cigna?

eviCore healthcare partners with Cigna to provide industry-leading benefit management solutions for key medical segments, including advanced radiology imaging, diagnostic cardiology, radiation therapy, and musculoskeletal services.

What is the phone number for eviCore members?

Were here to help! Thank you for submitting. You will be contacted by an eviCore representative within 5 business days. If you do not hear back from us within 5 business days, please call 800-792-8744, option4.

How do I contact eviCore?

You can also email portal.support@evicore.com or call 800-646-0418, option 2.