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Health Plans | Utilization Management


EviCore’s Musculoskeletal (MSK) utilization management solution addresses the full spectrum of potential care and treatment, from holistic and conservative approaches to more advanced procedures. We then apply up-to-date evidence-based guidelines and advanced technologies to ensure that the right care is delivered for safe, effective, and affordable MSK care.

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Services Covered

EviCore’s management of conservative care options for musculoskeletal (MSK) conditions covers the full range of specialized therapy, including massage, acupuncture, chiropractic, physical/occupational, and speech therapy. Unlike other medical disciplines where procedures occur at a single point in time, specialized therapy services are typically provided episodically over the course of weeks or months, enabling flexible and tailored application. 

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Specialized Therapy Management

EviCore’s specialized therapy management solution is condition-based and considers duration, frequency, and intensity when authorizing a number of visits. Avoiding the limitations inherent in authorizing specific modalities, our model allows the provider sufficient autonomy and flexibility to select and perform any one of the allowable procedures they deem medically necessary during the episode—based on the member’s presentation at the time of treatment.

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Delivery Methods

The delivery methods associated with EviCore’s specialized therapy management solution are comprehensive and adaptable. Program administration options include:

  • Application of clinical decision support tools
  • Traditional prospective or retrospective utilization reviews requiring prior authorizations and/or claim editing and repricing
  • Innovative bundled payment, value-based care, and network-management

EviCore’s goal is to collaborate with health plan and provider partners who assess varying levels of oversight to deliver optimized care. This customized and concierge-based approach incorporates market dynamics pivotal to utilization review in the therapy space.

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EviCore currently possesses proprietary and regional chiropractic, acupuncture, and therapy networks in collaboration with various medical professional associations, including comprehensive musculoskeletal care centers. On an ongoing basis EviCore develops and enhances existing networks based on client need. From a health plan perspective, a delegated model is advantageous as medical services are more closely managed to achieve healthier outcomes while reducing administrative expenses. For example, EviCore continues to be a market leader in providing program differentiators such as:

  • Value-based care
  • Credentialing/re-credentialing
  • Advanced and predictive analytics
  • Risk stratification
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Patient Activation

EviCore’s patient-activation tools focus on education and awareness to empower health plan members to make more informed decisions about their care. We provide educational resources about MSK conditions and various treatment options. In addition, our innovative SmartChoice program provides patient outreach to educate health plan members on the same quality, lower-cost options that are available for their diagnostic imaging procedure locations, as well as various conservative-care options available to them for the treatment of MSK pain. 

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Payment Integrity

Our integrated system, Claims Studio, delivers incremental savings through an enhanced focus on accurate claims payment, which can be applied as an extension of health plans’ existing claims workflows. In this process, the claim is pended in the host system; sent to EviCore, where it is adjudicated with EviCore’s proprietary system; and then returned to the host system for payment—all within the same day. In addition, Claims Studio encompasses appropriate edit checks that ensure MSK  services are rendered in accordance with the health plan benefits, authorizations, and network contracts.

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Behavioral Health

One goal of EviCore’s musculoskeletal (MSK) solution is to help members reduce chronic pain. EviCore employs a holistic approach and includes a behavioral health component to assist in mitigating pain. Through an integrated telehealth program, health plan members develop skills to change negative thoughts and behaviors related to pain. They also learn to identify fear-avoidance behaviors and utilize pain management techniques to enhance their coping skills, increase their confidence, and support their goals.

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Interventional Pain

Interventional pain procedures are an important component of our comprehensive pain management program. Statistics continue to show the broad and rapid increase in the prevalence of chronic pain, accompanied by significant increases in utilization and associated health care costs. Our philosophy for pain management services is to facilitate health plan members’ access to coordinated interdisciplinary care from appropriately trained specialists. Our efficient and timely prior authorization and utilization services are grounded in our use of evidence-based clinical guidelines to help reduce unexplained variation as well as unnecessary or duplicative care. 

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For more than 30 years, EviCore has expanded its breadth and depth of knowledge within the musculoskeletal (MSK) management space and established superior partnerships with each health plan client. Our surgical-management solutions are designed to collaboratively tailor the appropriate treatment with the right provider at the correct time for the patient. Innovative levers embedded in these solutions bring value beyond traditional utilization management and incorporate facilitated decision-making for implantables, acute level-of-stay management, and proactive discharge planning to ultimately realize healthier patient outcomes. Through our portfolio of MSK services, we also collaborate with our health plan clients to maximize the value of their network by promoting clinically appropriate, evidence-based guidelines and cost-effective care. 

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Patient Activation

Patients who are more knowledgeable about their health are more likely to use self-management techniques, adhere to treatment plans, and actively engage providers about their care. That’s why we help patients gain more knowledge and understanding about their health care through various patient activation strategies. 

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Payment Integrity

Our integrated Claims Studio system encompasses appropriate edit checks that are necessary to ensure MSK services are rendered in accordance with the health plan benefits, authorizations, and network contracts. 

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Implant Management

To better address product variation and the high costs related to implantable devices in surgical procedures such as total knee and hip replacements, EviCore developed an innovative solution that uses evidence-based clinical guidelines to detect safety and quality gaps in implant usage, and a thorough claims review process to identify and recoup potential and actual overpayments. Our expertise in promoting transparency and predictability into implantable device spend helps reduce medical expenditures for our clients. In short, EviCore’s implant management solution leads to better outcomes and more affordable healthcare. 

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Site of Care Optimization

EviCore’s musculoskeletal (MSK) Site of Care program is designed to improve member access to more appropriate and cost-effective sites of care for all MSK-related procedures and treatments, with no reduction in care quality and efficacy. We do this by influencing the selected location for MSK-related procedures, providing redirection support to help providers choose a more cost-effective location, and helping manage the inpatient length of stay, as needed. Patient safety is always our top priority, with financial factors only considered if we have established that a lower-cost facility would be equally (if not more) appropriate for their condition.

Frequently Asked Questions

All of EviCore’s clinical guidelines are stored on the musculoskeletal clinical guidelines page at (

The health plan has contracted with EviCore healthcare to assist with managing and administering benefits for interventional pain procedures; joint surgeries; spinal surgeries; physical, occupational, and speech therapy; chiropractic care; acupuncture; and massage therapy.

This program manages but is not limited to, the below member pain management services for the following.

  • Behavioral health
  • Interventional pain procedures
  • Opioids

This program manages the below member joint and spine services for the following.

  • Joint: (limited to shoulder, knee and hip) Replacement/arthroplasty, revision, arthroscopic and open procedures
  • Spine: Arthroplasty, discectomy, microdisectomy, fusion and grafts

This solution manages member joint and spine services for the following:

  • Joint: (limited to shoulder, knee, and hip) replacement/arthroplasty, revision, arthroscopic and open procedures
  • Spine: arthroplasty, discectomy, microdisectomy, fusion, and grafts.

This solution manages outpatient member services for the following:

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Chiropractic Services
  • Acupuncture
  • Massage
Musculoskeletal Insights
Clinical Expertise

I am responsible and accountable for the rigor associated with the clinical criteria that we use for prior authorization of musculoskeletal procedures. The strong evidence supporting our criteria allows us to make appropriate decisions on patients’ behalf. We are in the business of actually approving medically appropriate procedures, not denying them. 

Dr. Robert Westergan
Associate Chief Medical Officer for Connected Musculoskeletal Solutions

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