Health Plan: Overview

Health Plans are not only challenged with priorities regarding the bottom line and containing costs, they also must meet the needs and improve the health of members through support of value-based care. As a result, they need a medical benefits management partner who can bring value to the health plan; utilize cost-effective, evidence-based tools; and engage providers who support the practice of evidence-based medicine to contain costs and improve member health. Today, health plans also require tailored options and flexible approaches that enable speed to market and clinical, operational, and reimbursement features that can be customized to the client and the locality.


​eviCore healthcare's Solutions

Since 1992, eviCore healthcare (eviCore) has worked with health plans to develop evidence-based healthcare solutions that produce quantitative savings and a return on investment. Your eviCore team understands the unique challenges facing the industry today and will configure solutions to your plan’s specific requirements. As one of the country’s largest specialty benefits management companies, we provide value by applying cost-effective, evidence-based tools to engage providers in support of the practice of evidence-based medicine. We offer our solutions on a flexible and scalable UM platform, capable of accommodating a wide variety of client options, including claims payment options to meet local, regional, and multistate requirements as well as variably sized membership and management objectives. At the same time, eviCore’s longstanding national presence and in-depth experience provide the extra measure of value to the health plan’s national client members.

Nine Major Healthcare Solutions: eviCore offers more comprehensive healthcare solutions than any other company in our industry. For the health plan, this means that once a solution is implemented, additional solutions can be implemented with reduced implementation costs as we take advantage of existing IT and data transfer infrastructure. Familiarity will reduce the time and preparation associated with medical policy concordance as well as day-to-day vendor management.

Solution Flexibility: eviCore and the health plan can customize solutions to meet local-market needs. Each solution can be delivered with a range of options, from clinical decision support to clinical review with authorizations linked to claims (PA) that include certifications (approvals) and non-certifications (denials).

Evidence-Based Clinical Foundation: eviCore maintains the industry’s most comprehensive, well-documented, and up-to-date clinical criteria, overseen by solution-specific Medical Advisory Committees that comprise more than 200 nationally recognized academic and community-based, board-certified physicians. The committees meet regularly to review the appropriate clinical criteria and discuss technological advances and new evidence-based research that can impact the specific eviCore solution(s). The committees base the criteria on guidelines established by medical specialty societies, published research, and peer-reviewed literature. When new clinical information is available, updates to clinical criteria can be made within 24 hours. eviCore ensures more accurate clinical information collection, fewer provider callbacks, and a reduction in request time.

Minimum Network Disruption: Our commitment to minimizing disruption extends beyond that of our competitors; for example, we offer “on-the-ground” network support to the health plan’s internal team.

Next-Generation IT and Data Analytics: eviCore is the only medical benefits management company offering “IT Lite” implementation. The solution is vendor-hosted, so it reduces the IT burden for the health plan. Using EMC’s GreenplumTM data analytics processing and Microstrategy interactive reporting capabilities, eviCore offers the health plan insight and advanced reporting that no other vendor can match.

Ultimately, eviCore provides health plans with solutions that deliver the highest quality of value-based care and the most favorable clinical outcomes—for all stakeholders.