Currentcare_continuumPolicy 920-720-1832

Care Continuum (CCUM) management of medical-benefit medications

Customize your policy alerts

Sign up for care_continuum Policy 920-720-1832 alerts

Get alerted when Policy 920-720-1832 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines how Care Continuum (via EviCore) manages prior authorizations and medical-claim editing for injectable, infusion, and specialty medications under Network Health's medical benefits and how providers interact with the service.

Policy Summary

Payercare_continuum

PolicyCare Continuum (CCUM) management of medical-benefit medications

Policy CodePolicy 920-720-1832

Change TypeNon-substantive / informational

Effective DateN/A

Next Review DateN/A

Key ActionSubmit medical-benefit prior authorization requests through the EviCore provider portal (phone/fax accepted); obtain authorization numbers and approval letters when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/7EviCore portal availability

<10 minutesOnline review time

877-787-8705Care Continuum phone

877-860-8866Care Continuum fax

Coverage criteria and policy scope

Coverage criteria and processes

Coverage routing and prior authorization applicability based on administration and benefit type.

Covered when the routing and authorization channel match the medication administration and benefit determination as follows:

Administration & routing

If medication is self-administered injectable → considered under the pharmacy benefit; prior authorization requests submitted via CoverMyMeds or Express Path.
Links to CoverMyMeds/Express Path available on provider resources.
If medication is administered by a health care professional (injectable, infusion, specialty) → considered under the medical benefit; prior authorization requests submitted via the EviCore provider portal (Care Continuum).

A published list on the Provider Resources page identifies medical drugs that require prior authorization and includes respective J-codes; providers should consult that list when determining medical‑benefit prior authorization requirements.

Existing prior authorizations remain valid and will be applied until the original expiration date provided in the authorization.

When both medical and pharmacy benefits apply for different components of therapy (for example, an IV loading dose followed by subcutaneous maintenance), separate prior authorizations may be required through the respective channels (medical via EviCore; pharmacy via CoverMyMeds/Express Path).

Example: IV loading dose of ustekinumab (Stelara) may be authorized on the medical benefit while subsequent SQ doses require pharmacy benefit authorization.

Coding and existing authorizations

Medical drug J-codesmixedCovered

J-codes list

Medical drugs requiring prior authorization are listed with respective J-codes on the provider resources page

Existing authorizations handling

Existing authorization validityExisting prior authorizations remain valid and will be applied until the original expiration date shown on the authorization.

Scope of applicationThis applies to prior authorizations listed on the Provider Resources page for medical drugs requiring prior authorization (with J-codes).

Authorization referenceProviders should reference the original authorization number and expiration when submitting claims to ensure the prior authorization is honored.

Provider actions, portal access, and escalation

Prior Authorization

Prior authorization via EviCore

Care Continuum performs prior authorizations for medical‑benefit drugs through the EviCore provider portal. Providers can create, view, edit, search, renew requests, and when criteria are met an authorization number and approval letter are issued; Care Continuum also accepts phone and fax interactions for prior authorization inquiries.

Portal features: create new requests, view status, edit requests, search requests, renew approvals
Phone/fax interactions accepted in addition to the portal

Denial Risk

Denial and escalation process

If initial review criteria are not met, the case is escalated to a nurse for further review; the nurse may request additional information, and if criteria remain unmet a Care Continuum provider will review the case which may result in denial.

Representative screens using clinical decision trees; meets criteria → authorization number and approval letter
If criteria not met → sent to nurse review; nurse may request more information
If nurse confirms criteria not met → Care Continuum provider review and possible denial

Documentation Required

Portal registration and support

Providers should register for and use the EviCore provider portal to submit and manage prior authorization requests; for portal issues call 800-646-0418 (option 2) or email portal.support@eviCore.com.

Visit evicore.com to register and begin submitting prior authorizations online
For web portal issues call 800-646-0418, select option 2 or email portal.support@eviCore.com

Billing Rule

Benefit determination routing

Prior authorization routing depends on administration route: self‑administered injectables are handled under the pharmacy benefit (submit via CoverMyMeds or Express Path) while clinician‑administered injectables, infusions, and specialty drugs are managed under the medical benefit and submitted via EviCore/Care Continuum.

Self‑administered injectable → pharmacy benefit; prior auth via CoverMyMeds or Express Path
Administered by a health care professional (injectable/infusion/specialty) → medical benefit; prior auth via EviCore

Definitions and benefit distinctions

Medical benefit vs pharmacy benefit

Definition — medical benefit medicationsInjectable, infusion, and specialty medications administered by a health care professional are covered under the medical benefit and managed by Care Continuum (EviCore).

Definition — pharmacy benefit medicationsSelf‑administered injectable medications are generally covered under the pharmacy benefit and managed by the pharmacy benefit manager (Express Scripts).

Prior authorization routingPrior authorization requests for medical‑benefit drugs are submitted via the EviCore provider portal; pharmacy‑benefit prior authorizations use CoverMyMeds or Express Path.

When both benefits applyIf a therapy involves both medical and pharmacy settings (e.g., IV loading dose then SQ maintenance), separate authorizations may be required through the respective channels.

Policy Summary

Payercare_continuum

PolicyCare Continuum (CCUM) management of medical-benefit medications

Policy CodePolicy 920-720-1832

Change TypeNon-substantive / informational

Effective DateN/A

Next Review DateN/A

Key ActionSubmit medical-benefit prior authorization requests through the EviCore provider portal (phone/fax accepted); obtain authorization numbers and approval letters when criteria are met.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Care Continuum (CCUM) management of medical-benefit medications

Customize your policy alerts

Sign up for care_continuum Policy 920-720-1832 alerts

Get alerted when Policy 920-720-1832 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage criteria and policy scope

Coverage criteria and processes

Coverage routing and prior authorization applicability based on administration and benefit type.

Covered when the routing and authorization channel match the medication administration and benefit determination as follows:

Administration & routing

If medication is self-administered injectable → considered under the pharmacy benefit; prior authorization requests submitted via CoverMyMeds or Express Path.
Links to CoverMyMeds/Express Path available on provider resources.
If medication is administered by a health care professional (injectable, infusion, specialty) → considered under the medical benefit; prior authorization requests submitted via the EviCore provider portal (Care Continuum).

Existing prior authorizations remain valid and will be applied until the original expiration date provided in the authorization.

Example: IV loading dose of ustekinumab (Stelara) may be authorized on the medical benefit while subsequent SQ doses require pharmacy benefit authorization.

Coding and existing authorizations

Medical drug J-codesmixedCovered

J-codes list

Medical drugs requiring prior authorization are listed with respective J-codes on the provider resources page

Existing authorizations handling

Existing authorization validityExisting prior authorizations remain valid and will be applied until the original expiration date shown on the authorization.

Scope of applicationThis applies to prior authorizations listed on the Provider Resources page for medical drugs requiring prior authorization (with J-codes).

Authorization referenceProviders should reference the original authorization number and expiration when submitting claims to ensure the prior authorization is honored.

Provider actions, portal access, and escalation

Prior Authorization

Prior authorization via EviCore

Portal features: create new requests, view status, edit requests, search requests, renew approvals
Phone/fax interactions accepted in addition to the portal

Denial Risk

Denial and escalation process

Representative screens using clinical decision trees; meets criteria → authorization number and approval letter
If criteria not met → sent to nurse review; nurse may request more information
If nurse confirms criteria not met → Care Continuum provider review and possible denial

Documentation Required

Portal registration and support

Visit evicore.com to register and begin submitting prior authorizations online
For web portal issues call 800-646-0418, select option 2 or email portal.support@eviCore.com

Billing Rule

Benefit determination routing

Self‑administered injectable → pharmacy benefit; prior auth via CoverMyMeds or Express Path
Administered by a health care professional (injectable/infusion/specialty) → medical benefit; prior auth via EviCore

Definitions and benefit distinctions

Medical benefit vs pharmacy benefit

Definition — pharmacy benefit medicationsSelf‑administered injectable medications are generally covered under the pharmacy benefit and managed by the pharmacy benefit manager (Express Scripts).

When both benefits applyIf a therapy involves both medical and pharmacy settings (e.g., IV loading dose then SQ maintenance), separate authorizations may be required through the respective channels.