Ethics & Compliance

Ethics and Compliance

EviCore healthcare maintains a strong commitment to the delivery of quality healthcare services. We strive to deliver quality programs to those who access and purchase our products and services, including patients, providers, and payers. Our Network Ethics and Quality Program was created to support our ongoing commitment to high ethical and quality standards.

URAC Accreditation

EviCore healthcare has been granted a full, two-year quality accreditation for our health utilization management program issued by the American Accreditation HealthCare Commission/URAC. This distinction validates that EviCore healthcare meets stringent national standards in the areas of staff qualifications, program content and processes, patient confidentiality, accessibility and documentation.


Program Structure

EviCore healthcare's Quality Committee is responsible for the Ethics and Quality Program, including the development of ethics and compliance principles, communicating these principles to the network, and providing a method for addressing ethics and compliance exceptions and grievances.EviCore healthcare requires all contracted facilities to sign an acknowledgment confirming they have received and understand the program description and agree to abide by its principles.



EviCore healthcare believes that ethical behavior is the basis of clinical and business decision-making. We balance the rights of the patient, the involvement of other stakeholders, the company interests, and our community obligations. All decisions, first and foremost, must maintain the health and welfare of the individual. All business and treatment decisions must conform to the ethical principals that are the foundation of EviCore healthcare.

Quality Compliance

All network providers are required to adhere to state and federal compliance requirements. These regulations include but are not limited to the following: billing, coding, confidentiality of patient information, Medicare cost reporting, physician relationships, employment, self-reporting, records management, information security, business courtesies, and environmental compliance. EviCore healthcare is not responsible for updating providers on changes to state and federal compliance regulations. Network providers are required to call EviCore healthcare's Customer Service regarding incidents where providers are in breach or potentially in breach of applicable statues to report any alleged violations.

UM Decision-making

EviCore affirms that: 1) UM decision making is based only on appropriateness of care and service, and existence of coverage as communicated to EviCore by the policy issuer.  2) The organization does not reward UM decision makers-practitioners or other individuals-for issuing denials of coverage or service care. 3) The organization does not encourage decisions that results in underutilization or overutilization by UM decision makers.


Complaints and Grievance Policy

EviCore healthcare's customer Service Representatives are available to initiate complaint or grievance resolution. Complaints can be filed by telephone.

EviCore healthcare defines a grievance as any unresolved complaint concerning quality of care, contractual dispute, or appeals determination. We investigate each complaint and grievance, taking appropriate measures to ensure resolution of each issue and prevent similar occurrences in the future, if possible.

Any member, client, provider or party acting on the behalf of a member may utilize EviCore healthcare's Grievance Procedures. EviCore healthcare will address each applicable grievance and when appropriate, aid in forwarding the inquiry to the insurer. Complaints may be filed with a Customer Service Representative at 888-693-3211.

Customer Service Representatives have the ability to assign grievances to appropriate personnel for follow-up and resolution. Appropriate personnel includes but is not limited to the Director of Quality Management, Vice President of Network Development, and the Network Medical Director. In the event there is a complaint regarding medical information or medical issues concerning a member, EviCore healthcare encourages the Provider to address all issues through our Customer Service Department.

EviCore healthcare's complaints and grievances are investigated and an appropriate action plan implemented within 20 working days. Urgent issues are handled within 72 hours. All complaints and grievances are kept on file in EviCore healthcare's Customer Service Department.

A participant may appeal directly to the Quality Management Committee if he or she feels that their grievance has not been appropriately responded to and if they have formally filed a grievance with the EviCore healthcare Customer Service Department. The Committee is led by the Network's Medical Director and meets periodically to review all grievances relating to medical appropriateness and quality of care. The Committee reviews and analyzes grievances in order to improve the ethical and quality performance of the network.

Client health plans may choose not to delegate member service to EviCore healthcare. In this case, please refer to the health plan's Member or Customer Service Department typically located on the back of the plan's ID card. All complaints and grievances are considered privileged and confidential communications between EviCore healthcare, our providers, employees, and the insurer. Internal policies and applicable federal and state laws regarding confidentiality protect these documents.


Claims Billing

EviCore healthcare requires that providers submit all claims information on either a HCFA 1500 or UB-92 form. HCFA/UB forms must be completed in their entirety (HCFA 1500 - Box 1 through 33, UB92 - Box 1 through 86). Claims submitted to EviCore healthcare that do not meet these requirements will be entered into the EviCore healthcare claims processing system, denied for incomplete or insufficient information, and a remittance advice issued to the provider.

The network policy is that ICD-9-CM diagnosis and procedure codes and Current Procedural Terminology (CPT) codes must be correctly submitted and will not be modified or mischaracterized to be covered and paid. Diagnosis or procedure codes will not be misrepresented or mischaracterized by assigning codes for the purpose of obtaining inappropriate reimbursement. The procedural codes reported should accurately reflect the procedures performed during the encounter.

CPT-4 codes must be used for all claims submitted on the HCFA-1500 forms. Please refer to the CPT coding guidelines published by the American Medical Association and the Health Care Financing Administration for physician coding.

Diagnoses should be coded utilizing the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM). Please reference the Official Guidelines for Coding and Reporting diagnoses published in AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 1995 or the most current AHA Coding Clinic Guidelines.

Claim Dispute Issues

If a provider believes a denial to be in error, that provider may initiate the claims appeal process by sending a written request to the claims submission address, including supporting documentation to substantiate the claim. Providers who call EviCore healthcare's Customer Service line requesting an appeal will be faxed a copy of the claims appeal instructions. All claims appeals must be received in writing.

Final appeal decisions are made within 20 working days of receipt of all required information. Appeals related to claims denied for reasons related to precertification, medical necessity or repeat studies on the same date of service will be forwarded to the Chief Medical Officer or designee.


Customer Service

To better service our provider's needs, EviCore healthcare has a centralized Customer Service Department dedicated to serving the needs of members, providers, and clients. Customer Service Representatives can provide assistance with the following:

  • Lists of clients assessing the network
  • Referrals within the network
  • Listings of providers within your geographic area
  • Grievance procedures
  • Changes to your demographic information
    Address change
    Addition or closing of an office
    Billing address changes
    Telephone number changes

Customer Service can be reached at 888-693-3211, between 7 A.M. and 8 P.M. Central Time, Monday through Friday.