Ask EviCore: Site of Care
Hi, I’m Mark Tate, and thank you for reading this edition of Ask EviCore. My Provider Experience team is dedicated to continuously improving your experience with EviCore. For example, we relentlessly pursue a prior authorization process that is faster, more efficient, and more collaborative.
In addition, we use this column to answer your questions and share updates about our processes. This month, we’re exploring the Site of Care program. Before we dive in, I want to share two items with you. First, our primary goal—to ensure patients receive high-quality, patient-centric care that is cost-effective—was the key driver of this new program. Second, it’s important to know that a Site of Care review will not occur for every prior authorization request.
What is the Site of Care program?
The Site of Care program will ensure that patients receive high-quality care at the site that’s most appropriate and cost-effective for their needs. The program will apply to certain radiology, musculoskeletal (knee surgery), and gastroenterology procedures.
For example, a request for care administered in a hospital outpatient department versus an ambulatory surgery center or office setting may need to undergo a Site of Care review process. Also, some health plans will require precertification for high-tech radiology imaging that includes a medical necessity review for both the services requested and the service location.
How will a provider requesting a test or procedure know if the member is included in the Site of Care program?
Providers do not need to do anything; if a member is included in the Site of Care program, the precertification pathway in the prior authorization review process will seamlessly recognize the member without any effort from the provider.
How does the Site of Care program impact providers? Are there new steps to follow?
Site documentation and decisions occur concurrently with the existing prior authorization process, so there are no new administrative steps for the provider. There will be no change when ordering providers refer patients to a preferred location. If a provider directs a patient to an outpatient hospital setting and there’s a high-quality, lower-cost facility available, the provider will need to identify the clinical condition that warrants the need for the service to be performed in the hospital setting. In the absence of a clinical rationale, EviCore will not approve coverage for the service at the outpatient hospital setting.
There are clinical guidelines to help providers decide when a test or procedure should be performed in a hospital setting. This information is available via EviCore’s clinical decision support tool, which is also available to help determine whether a specific test or procedure is medically appropriate.
Providers will be given multiple options when deciding the best site of care. If a hospital setting is required because of certain clinical conditions, that information simply needs to be provided. If a hospital setting is not required, then EviCore can help the provider find the freestanding clinics that a patient’s health plan has designated as preferred locations.
How does the Site of Care program impact patients?
Patients may not be approved for certain in-scope services if their provider requests the service to be performed at an outpatient hospital setting without providing clinical rationale. EviCore will attempt to contact patients whose procedures have not been approved to explain the reasons and offer alternatives.
How far will patients need to travel for services if they are impacted by the Site of Care program?
We understand that traveling long distances can create additional burdens for patients. When no preferred location is available within a reasonable maximum distance, EviCore will permit the use of an outpatient hospital setting.
Do urgent requests require a Site of Care review?
No. All emergency care is exempt from the Site of Care review, allowing providers the flexibility to act with speed when needed. Services performed in an emergency room setting are already excluded from all precertification.
How will reconsideration requests be handled?
When a request for care is not approved, the patient and ordering provider will receive a letter that explains the various appropriate appeal options, such as a reconsideration or a clinical consultation called a peer-to-peer review.
Those seeking to learn more about the Site of Care program can:
- Read: Top Five Reasons to Consider Alternative Sites of Care for Certain Surgical Procedures
- Watch a Webinar: Leveraging Site of Care to Drive Affordability
- Reach out to your Regional Provider Engagement Manager. Contact information can be found on the territory map in the Provider's Hub section of www.eviCore.com.
If you have a question or a would like a specific topic covered in a future edition of the Ask EviCore column, or if you would like to share your feedback about our prior authorization process or this newsletter, email Jackie Jenkins, the National Provider Advocate on my team, at providernewsletter@evicore.com. Thanks for your continued partnership!