Reconsiderations

If we request a peer-to-peer clinical discussion for a treatment plan, but the provider does not respond or cannot meet, we reject the treatment plan. You process the treatment plan as you do other rejected treatment plans, and send the appropriate denial letters or faxes to the provider and patient.

Within an established period of time (for example, 30 days), the provider may contact us to request another peer-to-peer clinical discussion for that treatment plan. We may reopen the treatment plan to start what we call the reconsideration process.

We handle reconsiderations as we handle requests for new treatment plans. We review the treatment plan and either recommend approval or denial, or request your approval. You process the treatment plan as you do other treatment plans.

The only difference on the dashboard is the statuses that we assign to reconsidered treatment plans.

The following table describes where and in what status a treatment plan appears during the reconsideration process:
After this step... The treatment plan appears here on the dashboard...
We reopen the treatment plan and start the review and peer-to-peer process.

Code Denials and All Records tabs, with a status of Pending Reconsideration.
We complete the peer-to-peer clinical discussion, and we request that you approve the treatment plan.

Approval Req'd tab, with a status of Pending Reconsideration.

The Authorization and Decline links appear in the Payer Action column.
We approve the treatment plan, or you authorize the treatment plan. Eviti Code and All Records tabs, with a status of Reconsideration Overturned, followed by the Eviti code, for example, Reconsideration Overturned: EV-MO-JP-0101-AEWMX7, which means the denial was overturned.
We reject the treatment plan, or you decline the treatment plan. Code Denials and All Records tabs, with a status of Reconsideration Upheld: Eviti Code Not Issued, which means the denial was upheld.