Sep 23rd 2019

Ask eviCore: Clinical Guidelines

Hi, I’m Mark Tate, and I lead eviCore’s Provider Experience team. We want to hear from you and continuously improve our interactions so that your experience with eviCore is easier, faster, and more collaborative.

This month’s Ask eviCore feature explains how our clinical guidelines are developed and how to navigate them. Together, we can ensure your patients get the test, treatment, or procedure that will best serve their needs.

Following are a few FAQ’s regarding our guidelines.

How are eviCore’s Clinical Guidelines Developed?

eviCore’s evidence-based clinical guidelines are based on the most current information from medical societies, as well as scientific evidence from recently published, peer-reviewed medical literature. As part of our guideline-development process, we collaborate with solution-specific medical advisory committees comprising more than 200 nationally recognized academic- and community-based board-certified physicians.

Our guidelines are used to help guide decision-making in how to diagnose, manage, and treat patients. They’re updated annually at minimum and are completely transparent and available to anyone through the eviCore website.

In this brief video, listen to some of our medical directors talk about how our clinical guidelines are formed:

How Can I Find eviCore’s Clinical Guidelines?

eviCore is committed to transparency for both patients and their healthcare providers. As mentioned above, our evidence-based guidelines are publicly available to anyone visiting the eviCore website. Here’s a step-by-step guide for finding the right ones:

- Visit:
- Under “Resources” in the top right-hand corner, selectClinical Guidelines
- Choose the relevant Solution
- If needed, accept the disclaimer
- Type in the relevant health plan
To view all eviCore guidelines, type in “eviCore healthcare” as the health plan.

Does eviCore Have Pediatric Guidelines?

Yes, eviCore is unique in that we maintain dedicated pediatric guidelines. To access them, follow the steps above to reach the guidelines section for each solution and health plan. For imaging, there may be separate documents for pediatric guidelines that can be found by scrolling down below the standard guidelines.

How Can I Search For The Guidelines I Need?

There are several ways you can find the guidelines you need.

Method 1:

- Navigate to the health plan-specific guidelines by visiting the eviCore clinical guidelines page, select the relevant Solution, and then type in the health plan.
- You can then search within the displayed guidelines using the search by keyword feature available on the right side of the page.

Method 2:

- You can also directly access the guidelines themselves. For example, you can follow the steps above to reach the appropriate guidelines document. Within that document, you can refer to the detailed table of contents, where most guidelines are grouped anatomically or by condition. You can also search within the PDF document using key words, like a condition name or description. Finally, all eviCore guidelines list matters by CPT code, so you can search using that information, too.

Method 3:

- You can also use our “Search” feature at It’s located in the top right corner of our home page, directly below the “Resources” button where a link to our full clinical guidelines can be found.
-  Using Search, you can type in “pediatric neck imaging” or specific CPT code “71250,” for example, and an extensive list of links will populate. You’ll also find buttons on the right to narrow your search to forms (which include our clinical worksheets) and guidelines. If you know the patient’s health plan, include it in your search. Please note: if a guideline is labeled as “ALL,” that indicates that it is an eviCore healthcare generic guideline.

You are invited to continue to share your feedback, suggestions, and questions about our Prior Authorization process and this newsletter.

Jackie Jenkins, the National Provider Advocate on my team, will connect with you soon. 

I look forward to answering more of your questions in future editions of this newsletter. Sincere thanks for your continued partnership with eviCore.

Mark Tate
Master of Physical Therapy
Vice President, eviCore Provider Experience