Government: Overview

With the experience of managing 40+ Medicaid clients, eviCore healthcare’s utilization management capabilities help ensure quality healthcare services for Medicaid and Medicare programs.


We recognize that for most healthcare-related government agencies, supporting the beneficiaries’ quality of life is the central mission. eviCore healthcare improves members’ lives by furnishing high-value, high-quality healthcare that delivers the appropriate tests and services at the appropriate time. We achieve this through our flexible and scalable utilization management platform which is capable of clinical, operational, and reimbursement options, including claims payment options to meet local, regional, and multistate requirements. A by-product of managing these services correctly is a reduction in spending, which is so important in today’s budget-conscious climate. While our radiology benefits form the base program that we manage for almost all of our state Medicaid clients, for some clients we manage up to nine of our solutions.

Our membership analyses across multiple current client populations show the following averages:

  • Our solutions collectively impact at least 35% of clients’ membership
  • Our solutions address more than 25% of a plan’s total claims expense – much of which had been previously unmanaged.

We also manage services for several Medicare Advantage plans as well as participate in a bundled payments project for Medicare fee for service.

As a URAC-accredited/NCQA-certified utilization management (UM) organization, eviCore applies the quality standards promoted by these organizations to all lines of business, programs, and client members.