Provider Toolbox

Welcome to the eviCore EAP "Provider Toolbox"

This toolbox provides you easy access to the manual and forms you will need to facilitate an effective EAP appointment(s) and subsequently submit a claim for reimbursement. Each of our EAP agreements is customized by our employers to determine the total number of EAP appointments available. That information will be sent directly to you from eviCore EAP. If you are new to our network, or you haven’t seen an EAP customer within the last 30 days, please take a moment to review the EAP provider manual. If you need any assistance from the EAP program, please call us at 1-888-276-6632.

EAP Provider Procedures Manual

If you are new to our network, or you haven’t seen an EAP customer within the last 30 days, please take a moment to review the EAP Provider Procedures Manual.

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Sample EAP Authorization Form

This form will be sent to you by the EAP at the time of the referral. It contains the member number and authorization number that is needed when filing out the CMS 1500 for billing.

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EAP Assessment

This form is completed by the provider during the initial EAP appointment and is retained by the provider.

Statement of Understanding

This form is reviewed and signed by the EAP client during the initial EAP appointment. The provider gives a signed copy to the EAP client and retains the original.

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Statement of Client’s Rights and Responsibilities

This form explains the EAP client’s rights and responsibilities within and beyond the EAP benefits and is given to the EAP client by the provider during the initial EAP appointment.

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Statement of EAP Client Complaint Resolution Procedure

This form explains the procedure used by eviCore EAP to process client complaints and is given to the EAP client during the initial EAP appointment with the provider.

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Authorization for Disclosure of Confidential Information

This form is signed by the EAP client and is utilized by the EAP provider to exchange information with a third party. It is retained by the provider. Please feel free to use your own Authorization form if you choose.

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EAP Provider - Communication Form

This form is sent to EAP providers by the EAP when an employee is administratively referred by their employer to the EAP. Complete this form and return to the EAP as soon as possible.

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Treatment Provider - Communication Form

This form is sent to Treatment providers by the EAP when an employee is administratively referred by their employer to the EAP, but is participating with the provider through direct services (e.g. health insurance or cash). Complete this form and return to the EAP as soon as possible.

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EAP Claims Processing Instructions

All billing to eviCore EAP needs to be mailed the the EAP on a CMS 1500 red and white form.