To get a specialty medication approved under a patient’s medical benefit, download the medication-specific CareContinuum prior authorization form, gather the patient’s insurance and clinical records, and submit the request through the EviCore provider portal at evicore.com for the fastest decision. CareContinuum, an Express Scripts/Evernorth company, reviews these requests against the plan’s clinical criteria, and online submissions can sometimes return a real-time approval in minutes.11199SEIU Funds. CareContinuum Medical Drug Benefit Management Program The form is drug-specific, so make sure you have the correct version for the medication you plan to prescribe before you start filling anything in.
What to Gather Before You Start
Every request needs two kinds of information: identifiers and clinical justification. Pulling it all together before you open the form prevents the back-and-forth that slows decisions.
Patient and Provider Identifiers
The top of the form asks for the patient’s full legal name, date of birth, and the member ID printed on their insurance card.2Network Health. Care Continuum Frequently Asked Questions On the provider side, you need your National Provider Identifier and the facility’s tax ID. Verify these against what the plan has on file. A mismatched NPI triggers a technical denial that never reaches a clinical reviewer, and those bounce-backs waste days.
Clinical Documentation
Clinical justification is where requests are won or lost. Include ICD-10 diagnosis codes for the condition and the HCPCS or J-codes for the specific drug.2Network Health. Care Continuum Frequently Asked Questions Add the drug name, dose, route, and frequency. Then attach the records that establish medical necessity: recent labs, imaging, and documentation of alternative therapies the patient already tried and why those failed. That last piece carries real weight. A request for a costly biologic without evidence of a first-line therapy trial is one of the most common reasons reviewers deny.
How to Submit the Form
CareContinuum takes requests through several channels, and the one you pick affects how fast you hear back.
EviCore Provider Portal
The EviCore portal at evicore.com is the primary electronic submission route and the one most likely to produce a same-day decision.2Network Health. Care Continuum Frequently Asked Questions After signing in, choose the patient’s health plan and applicable solution, then enter the diagnosis codes, drug information, and clinical details. You can upload labs and chart notes directly. The portal issues a tracking number and lets you check status at any hour. Providers without an account can register at evicore.com.
Surescripts and CoverMyMeds are additional electronic options that may already be built into your EHR.3Evernorth Health Services. Prior Authorization Resources When an EHR supports electronic prior authorization, straightforward cases can move in minutes.
ExpressPAth Real-Time Review
For certain plans, CareContinuum’s ExpressPAth system can issue an instant approval based on how you answer an online clinical questionnaire. If your answers meet plan criteria, the authorization is approved on the spot and will not be reversed. If the system cannot auto-approve, the case routes to a nurse case manager and possibly a medical director for manual review. A system-generated “denial reason” may show up in that interim window; it is not a final denial, and a human reviewer makes the actual determination.4Accredo. ExpressPAth Quick Start Guide
Fax and Phone
If electronic submission is not available, fax the completed medication-specific form. For 1199SEIU plans, the fax is 866-343-1880, and the phone line at 877-273-2122 is staffed Monday through Friday, 8:00 a.m. to 7:00 p.m. Eastern.5Accredo. 1199 SEIU Benefit Funds Fax numbers vary by plan and drug category, so always use the number printed on the header of the specific form you downloaded. Sending to the wrong line adds days.
Keep proof of submission. Print the fax transmission report. Save the portal tracking number. If there is ever a dispute about when the request was filed, that documentation settles it.
How Long a Decision Takes
Turnaround depends on the plan type, the submission channel, and whether the case qualifies as urgent. Online submissions through the EviCore portal or ExpressPAth often return a decision in under ten minutes when the case meets auto-approval criteria.2Network Health. Care Continuum Frequently Asked Questions When manual clinical review is needed, the applicable regulatory deadlines apply:
- Medicare Part D standard requests: a decision within 72 hours of receiving the prescriber’s supporting statement.6Centers for Medicare & Medicaid Services. Medicare Part D Enrollee Grievances, Coverage Determinations, and Appeals
- Medicare Part D expedited requests, where standard timing could seriously jeopardize the patient’s health: a decision within 24 hours.6Centers for Medicare & Medicaid Services. Medicare Part D Enrollee Grievances, Coverage Determinations, and Appeals
- Medicaid and CHIP under the CMS Interoperability Rule, for non-drug items and services: 7 calendar days for standard requests and 72 hours for expedited. A proposed extension of these rules to drug prior authorizations has a compliance date of October 2027.7Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F8Centers for Medicare & Medicaid Services. 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule
- Commercial plans: generally 2 to 15 calendar days for standard requests, varying by state regulation and plan contract.9Express Scripts. How Long Does It Take to Complete a Coverage Review (Prior Authorization)?
Decisions post in the EviCore portal first, with an authorization number for approvals or a specific reason for denials. A written notice is also mailed to the provider and the patient. If the plan delivers an adverse decision by phone, a written denial letter must follow within three calendar days.6Centers for Medicare & Medicaid Services. Medicare Part D Enrollee Grievances, Coverage Determinations, and Appeals A status of “pending” or “additional information requested” means the clinical team needs more documentation. Respond quickly, because the review clock can pause while the case is incomplete, and some plans treat extended inactivity as a withdrawal.
Why Requests Get Denied
Knowing what trips up reviewers helps you build a cleaner first submission. EviCore points to four recurring reasons for clinical denials:10EviCore by Evernorth. How to Make Prior Authorization Painless for Patients
- Insufficient clinical information. The reviewer cannot establish medical necessity from what was submitted. Missing lab values, incomplete chart notes, and vague condition descriptions are the usual causes.
- No trial of a first-line or conservative therapy. If the patient has a documented reason for skipping that step, such as an allergy, a contraindication, or a prior adverse reaction, state it in the request.
- A required precursor test or procedure is missing. Some drugs require a specific diagnostic result (imaging, biopsy, genetic marker) before the plan will authorize them.
- The clinical question is not stated clearly. This happens most when diagnosis codes do not align with the drug’s approved indications.
Technical denials — wrong NPI, mismatched member ID, expired coverage — are a different category and never reach clinical review. Verify eligibility and demographics up front and you avoid them entirely.
Renewing an Authorization Before It Expires
An approved authorization lasts until the expiration date stated in the authorization notice. The length varies by drug and plan: some approvals run six months, others a year, others for the plan year. The expiration date is listed in the portal alongside the authorization number.
You can submit a renewal through the EviCore portal up to 90 days before the current authorization expires.2Network Health. Care Continuum Frequently Asked Questions Start early. If you wait until the last week and the renewal gets delayed or denied, the patient faces a therapy gap. Renewal requests go through the same clinical review as new ones, so include updated labs and recent treatment notes showing the medication is still appropriate.
If the Request Is Denied
A denial is not final. The appeal path usually has two stages: an internal appeal with the patient’s health plan, and an external independent review if the internal appeal does not succeed.
Internal Appeals and Peer-to-Peer Review
Appeals of CareContinuum clinical denials are generally handled by the health plan’s own appeals department, not by CareContinuum.2Network Health. Care Continuum Frequently Asked Questions The denial letter lists the correct contact information for the applicable plan. For Medicare Advantage enrollees, CMS requires at least 60 calendar days from the denial notice to file. Commercial plans generally allow 180 calendar days, though some set shorter windows.
Before filing a formal appeal, consider requesting a peer-to-peer review: a phone call between the prescribing provider and the clinical reviewer who evaluated the case. Have the patient’s full chart, relevant practice guidelines, and documentation of failed alternatives ready. You can ask for a reviewer who specializes in the relevant clinical area. If the peer-to-peer does not overturn the decision, submit the formal written appeal.
External Review
Once internal appeals are exhausted, the patient (or a representative, which can include the prescribing provider) can request an independent external review. File in writing within four months of the final internal denial notice.11HealthCare.gov. External Review External review is available when the denial involves medical judgment, when treatment is deemed experimental, or when coverage was rescinded.
Standard external reviews must be decided within 45 days. Expedited reviews for urgent cases must be resolved within 72 hours. There is no charge if the plan participates in the HHS-administered federal external review process; other external review pathways cannot charge the patient more than $25.11HealthCare.gov. External Review
Don’t Administer the Drug Without Authorization
Administering a specialty drug before authorization is approved creates a billing problem that lands on someone. If the claim is denied because no authorization was in place, the responsibility shifts based on the denial code: sometimes the provider’s office absorbs the cost and cannot bill the patient, sometimes the patient owes the full charge. Confirm authorization status before the drug is given. If the clinical situation is urgent, submit an expedited request rather than skipping the authorization step.