EviCore (Evernorth) Prior Authorization API
EviCore (formerly CareCore National, acquired by Cigna/Evernorth) utilization management and prior authorization REST API for health plans, providers, and integrated delivery networks managing specialty care and imaging authorization. Enables AI agents to manage prior authorization submission for specialty procedures (imaging, oncology, musculoskeletal, cardiology) for provider authorization workflow automation, handle authorization status inquiry and real-time determination for clinical decision support automation, access clinical criteria and coverage determination guidelines for provider pre-authorization education, retrieve authorization approval, denial, and peer-to-peer review notification for provider revenue cycle automation, manage appeals and reconsideration submission for denied authorization workflow, handle P2P (peer-to-peer) review scheduling and physician-to-physician clinical discussion coordination, access authorization validity period and quantity tracking for authorization utilization management, retrieve case management referral and care coordination for complex case automation, manage real-time authorization web service for point-of-care clinical decision, and integrate EviCore with EHR systems (Epic, Cerner), RCM platforms, and health plan portals for end-to-end authorization lifecycle.
Score Breakdown
⚙ Agent Friendliness
🔒 Security
Specialty UM/prior auth. HIPAA, SOC2, ISO27001. OAuth2. US. Patient PHI and clinical authorization data.
⚡ Reliability
Best When
A healthcare provider organization, integrated delivery network, or health system wanting AI agents to automate prior authorization submission, status tracking, appeals management, and clinical documentation for specialty outpatient services managed by EviCore/CareCore.
Avoid When
HIPAA MINIMUM NECESSARY PHI IN AUTHORIZATION SUBMISSIONS: Automated prior authorization submission must include minimum necessary clinical documentation (diagnosis, clinical notes, supporting evidence) for the specific procedure; automated submission of excessive PHI beyond what EviCore clinical criteria require creates HIPAA minimum necessary violation and unnecessary PHI exposure. AUTHORIZATION DENIAL AS FINAL COVERAGE DETERMINATION: Automated treatment decisions based on EviCore authorization denial must preserve physician clinical judgment override; automated cancellation of clinically necessary services based on EviCore denial without physician review creates patient abandonment liability; authorization denial is a coverage determination, not a clinical guideline. PEER-TO-PEER REVIEW PHYSICIAN AVAILABILITY COORDINATION: Automated P2P review scheduling must verify ordering physician availability before scheduling EviCore medical director call; automated P2P scheduling without physician confirmation creates physician scheduling conflict and missed P2P window for denied authorization appeal.
Use Cases
- • Submitting prior auth requests from provider RCM agents
- • Checking auth status from clinical workflow agents
- • Appealing denials from revenue cycle agents
- • Tracking auth validity from utilization management agents
Not For
- • Pharmacy drug prior authorization (use CoverMyMeds or Surescripts)
- • Hospital inpatient admission authorization
- • Workers compensation utilization review
Interface
Authentication
EviCore uses OAuth 2.0 with scopes. REST API with JSON. Bluffton, South Carolina HQ (EviCore healthcare). Founded as CareCore National 2004. Acquired by Cigna in 2018 as part of Evernorth Health Services. Evernorth is Cigna's health services segment. EviCore manages specialty utilization management for 100M+ covered lives for 60+ payer clients. Specialty focus: imaging, oncology, musculoskeletal, cardiology, neuro, genetic testing. Largest independent specialty UM company. Competes with Cohere Health, Magellan Health, and AIM (Anthem) for specialty prior authorization.
Pricing
Bluffton SC. Cigna/Evernorth subsidiary. Founded 2004 as CareCore. 100M+ covered lives. 60+ payer clients. Enterprise payer and provider contracts for API access.
Agent Metadata
Known Gotchas
- ⚠ HIPAA BAA REQUIRED BEFORE ANY PHI SUBMISSION: EviCore API transmits patient PHI (diagnosis, procedure, clinical documentation); automated provider integration requires executed HIPAA Business Associate Agreement (BAA) with EviCore before any PHI transmission; automated PHI submission without BAA creates HIPAA violation
- ⚠ AUTHORIZATION DENIAL PHYSICIAN REVIEW MANDATORY: Automated treatment cancellation or rescheduling based on EviCore authorization denial must require ordering physician review; authorization denial is a coverage determination, not a clinical recommendation; automated cancellation of clinically necessary services without physician review creates patient abandonment liability and Joint Commission compliance issue
- ⚠ PAYER CONTRACT SCOPE FOR AUTHORIZATION ENDPOINT ACCESS: EviCore manages utilization management for specific health plan clients under contract; automated authorization submission for a patient covered by a payer NOT contracted with EviCore will receive system rejection; verify patient payer-EviCore contract relationship before automated authorization submission
- ⚠ Clinical documentation attachment for complex cases — automated authorization submissions for complex specialty procedures (oncology, genetic testing, advanced imaging) require supporting clinical documentation (physician notes, prior treatment history, lab results); automated submission without complete clinical documentation package creates immediate denial or additional information request delay
- ⚠ P2P review scheduling window constraint — EviCore peer-to-peer review requests must be submitted within specified timeframe after denial (typically 2-14 days depending on payer and service type); automated denial detection must immediately trigger P2P scheduling workflow to meet deadline; missed P2P window forfeits physician appeal opportunity for denial
- ⚠ Authorization validity and quantity management — automated downstream scheduling of authorized services must track EviCore authorization validity period (start/end date) and authorized quantity (number of approved services); automated scheduling beyond authorized quantity or after validity expiry creates unauthorized service and payer claim denial
Alternatives
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Scores are editorial opinions as of 2026-03-07.