Healthcare Glossary
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Appeal
A request by the member to the health plan to review or change a decision regarding a claim.
Automation
The method of making a system, process, or machine function without human control. EviCore’s IntelliPathSM prior authorization solution employs automation for more immediate approvals.
Cancer Treatment
The use of surgery, radiation, medication, and/or other therapies to shrink or stop the progression of cancer. (Source: Mayo Clinic)
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Cardiovascular
The branch of medicine that studies and treats diseases and abnormalities of the heart.
Care Coordination
The organization of patient treatment and sharing of information among the principal participants to achieve safer and more effective care. Source (AHRQ)
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Caregiver
An individual who provides care for someone who is sick, elderly, or disabled. Source (Merriam-Webster)
EviCore content reference(s):
What digital resources can I access to find out more information?
Case
A request for a Medical Necessity review of a proposed treatment or procedure.
Chiropractic Care
The care and treatment of neuromusculoskeletal complaints through manual manipulations and/or adjustments of the joints and spine. Source (Spine Health)
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Claim
A payment request to Medicare or other health insurance. When you get care from an in-network doctor or other provider, they will send a claim to your health insurance carrier, and ask to be paid for services. Payment is based on the services covered under your health plan.
Claims Studio
A suite of claims management services from EviCore that performs administrative functions, rectifies errors or oversight, and ensures payment integrity.
EviCore healthcare (EviCore®)
A medical benefits management company offering solutions to help health plans and other organizations reduce costs while increasing the safety and quality of care for members. EviCore empowers the improvement of care by connecting patients, providers, and health plans with intelligent, evidence-based solutions to enable better outcomes.
EviCore intelliPath ®
An EviCore solution that simplifies prior authorization and removes barriers to evidence-based care through intelligence and automation.
EviCore onConnect℠
EviCore's comprehensive oncology suite that combines our capabilities in Medical Oncology, Radiation Oncology, Radiology, and Genomic/Molecular Laboratory to create a holistic, patient-centered care model.
EviCore's Solutions
EviCore works with providers for comprehensive care management in the following areas: Cardiology, EviCore onConnectSM (Comprehensive Oncology), Gastroenterology, Lab Management, Medical Oncology, Musculoskeletal, Post-Acute Care, Radiation Oncology, Radiology, Sleep, and Medical Drug Management.
Evidence-Based Care
An approach to medicine that emphasizes the application of the current best evidence in making decisions about the care of individual patients.
EviCore content reference(s):
Good News for Evidence-Based Care
Can Ready Access to Evidence-Based Guidelines Improve Patient Outcomes?
Gastroenterology
The medical specialty that studies, diagnoses, and treats digestive system disorders. Source (MedicineNet)
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Health Plan
A plan of healthcare coverage that a payer offers either directly to a group of members, or to members on behalf of an employer.
HIPAA
Acronym for Health Insurance Portability and Accountability Act of 1996, federal legislation that provides data privacy and security provisions aimed at safeguarding medical information. Source (TechTarget)
Home Health Care
Health care services that can be provided in a patients' home or residence usually after an acute event or diagnosis. Source (MediCare)
In-Network
Providers or care facilities that are part of a health plan’s network of providers. Source (HealthInsurance)
Laboratory Management
Utilization management of care involving laboratory processing of diagnostic tests and procedures, including genetic testing through evidence-based clinical policies, medical necessity review, and related claims-payment rules.
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Long-Term Acute Care Facility
Facilities which specialize in the treatment of patients with chronic or debilitating conditions to manage once they have been discharged from intensive care or diagnostic procedures, but who need to be more closely attended than a standard assisted living situation. Source (ASHA)
Managed Care
The application of healthcare coordination to help lower costs while improving the quality of care. A managed care organization offers health plans such as HMOs, PPOs, POSs, and PFFSs.
Medical Benefits Management
The application of utilization management to medical specialty solutions. This includes the process of reviewing medical-services requests in terms of medical necessity and appropriateness, and, when needed, steering care toward safer, more effective, and more affordable alternatives, given the patient’s condition and scope of benefit coverage.
EviCore content reference(s):
Medically Necessary or Medical Necessity
Healthcare services or supplies that meet accepted standards of medicine and are needed to diagnose and/or treat an illness, injury, or condition (chronic and acute) and associated symptoms.
(1) according to applicable law and/or regulations, are required to be provided to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms; or in absence of such definition,
(2) a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:
(a) in accordance with Generally Accepted Standards of Medical Practice;
(b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and
(c) not primarily for the convenience of the patient, physician or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease.
Medicare
A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Source (Healthcare.Gov)
Out-of-Network
A healthcare provider or facility that does not have a contract with a patient's health plan.
Patient Care Coordinator
A trained health professional who helps to manage a patient's care, including monitoring and coordinating the patient’s treatment plans, educating them about their condition, connecting them with healthcare providers, and evaluating their progress.
Payer
A payer is a company that offers health plans. You pay a monthly premium to the company. And they help pay for your healthcare expenses.
Peer-to-Peer (P2P) Consultation
When a prior authorization request does not meet evidence-based medical guidelines, the patient’s provider who submitted the prior authorization request can schedule a phone call with an EviCore medical director to discuss the patient’s medical condition. These are called peer-to-peer discussions, and they allow for the exchange of additional clinical information. These discussions may result in upholding the original decision that a request is inappropriate or issuing an alternative recommendation. The original decision that a request is inappropriate may also be overturned due to additional information being provided and the request being approved during the peer-to-peer. These discussions often result in a more informed decision about whether to do a certain test, treatment, or procedure.
Physician
A person educated through both schooling and clinical apprenticeships and who is licensed to practice medicine. This includes a diverse range of practices and specialties.
Post-Acute Care (PAC)
Rehabilitation or palliative services prescribed after an acute emergency incident. These may include a stay in a facility, ongoing outpatient therapy, or care provided at home. The ultimate goal is to transition the patient to their home in a timely manner.
Prior Authorization
A process by which EviCore makes an evidence-based determination regarding whether a particular requested healthcare service or supply should be covered under a Member’s healthcare benefits coverage (which may include, among other items, Medical Necessity determinations). In addition, may include automated processes, processes and procedures relating to the level and intensity of review applicable to particular services and Providers, and processes for authorizations without review, and consistent with Applicable Laws.
EviCore content reference(s):
Provider
A physician, non-physician health care practitioner, hospital or other facility, supplier, or other individual or entity involved in the delivery of health care services or benefits.
Radiation Oncologist
A doctor in the medical specialty that treats cancer with the use of radiation (X-rays, gamma rays, or electrons).
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Radiology
The study and branch of medicine concerned with the use of radioactive material in the diagnosis and treatment of a condition or disease.
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Rehabilitation Services
Special healthcare services that help a person regain physical, mental, and/or cognitive (thinking and learning) abilities that have been lost or impaired as a result of disease, injury, or treatment.
Sleep Solution
A utilization management program of sleep diagnostic procedures and positive airway pressure (PAP) therapy devices and supplies applied following the initial diagnosis of sleep apnea, as well as to improve long-term adherence to PAP compliance.
EviCore content reference(s):
SmartChoice
This EviCore program makes patients aware of available facility options for imaging tests such as MRI, CT, and PET scans. All referred locations are accredited to ensure they meet the highest standards for quality and safety, and each option provided is convenient for the patient. This program is important because significant cost differences among equal-quality imaging tests can exist, even within the same geographic area.
Spinal Surgeries
Procedures that change a patient's anatomy with the purpose of providing pain relief. Each of the EviCore programs for the utilization management (UM) of Spine Surgery and Joint Surgery of the shoulder, hip, and knee applies evidence-based clinical guidelines for the determination of medical necessity. Whether applied to minimally invasive spinal surgery or spinal fusion, knee arthroscopy, or total knee replacement, our clinical management and evidence-based guidelines are the core of our approach. Source (SpineHealth)
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Transitional Care
The continued care of a patient and coordination of services during a change from one healthcare setting to either another or to home care, or to a new practitioner when managing a course of treatment.
Utilization Management (UM)
URAC, which accredits companies like EviCore, defines utilization management as “the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities.” Prior authorization is one of the many aspects of utilization management that EviCore manages.
Waste
The misuse or overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system. Waste is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Appeal
A request by the member to the health plan to review or change a decision regarding a claim.
Automation
The method of making a system, process, or machine function without human control. EviCore’s IntelliPathSM prior authorization solution employs automation for more immediate approvals.