Lab Management: Overview

eviCore’s Laboratory Management solution utilizes more than 300 test-specific and most current medical policies and prior authorization guidelines to improve quality care and reduce genetic-testing costs. Prior authorization is performed using a strategic set of CPT codes and tests. In addition, the solution achieves significant reduction of inappropriate cost by leveraging thousands of lab-specific claims rules.

  

Everyone benefits through better outcomes

  • Plans

    Our Lab Management solution enforces evidence-based policies and utilizes trained genetic testing experts to ensure that the genetic lab services provided to patients are medically necessary, in accordance with their benefit policy, and in support of clinically appropriate and cost-effective care.

  • Providers

    Our Lab Management solution provides opportunities to educate physicians about the appropriateness of a genetic test in a given clinical scenario and, when applicable, to present the option of redirecting to a more appropriate genetic test. Such interactions not only provide education on the particular case discussed during the optional peer-to-peer, but also positively influence the future ordering behavior of those providers.

  • Patients

    Our Lab Management solution offers a patient-centric approach that ensures patients are provided the most appropriate evidence-based care and treatment. eviCore can also assist in redirecting tests to in-network laboratories when possible, potentially reducing out-of-pocket costs for patients.

  

Criteria & Easy Approval Process: Leading To Better Decisions

MD Review Appropriate Decision Web Phone Peer to Peer Genetic Counselor Review Methods of Intake REAL-TIME DECISION
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The more we know, the better the outcome

A list of the most common questions about the Lab Management program are provided below. For more detailed information, visit the Contact Us page.

How are policies created and updated?

Lab policies are written internally by genetic counselors and reviewed by internal and external medical advisory boards. Policies are reviewed at least semi-annually but are updated more often if significant new evidence is identified. eviCore reviews peer-reviewed publications and guidelines from all major professional societies when creating clinical policies.

What claims are subject to claims review?

Technically, all claims for CPT codes that are in scope are subject to claims review. eviCore reviews the claim to make sure it had any necessary prior authorization. In addition, eviCore automatically applies over 44,000 lab-specific claim rules to ensure appropriate reimbursement for medically necessary tests. The vast majority of these rules apply to low-cost, high-volume tests that are not as amenable to prior authorization.

How does eviCore handle large gene panels?

Most panels require prior authorization. eviCore reviews the medical necessity of each gene within a panel and typically only prior authorizes and recommends reimbursement for those genes that are medically necessary. eviCore believes that cost effectiveness should not be the only variable when reviewing a panel. Many panels include genes that have no clinical utility. If one of those genes has a mutation, the physician may not have evidence-based guidance to determine the best course of action. As a consequence, the physician may decide to follow the most stringent treatment or medical surveillance protocol which might not be necessary. All of this may cause the patient to suffer undue anxiety as well.

What if I have a question about a prior authorization result?

Both the referring and rendering provider, if known, will receive a copy of the determination correspondence for each case review. Providers can contact eviCore at the number provided on the case correspondence to discuss a prior authorization decision or schedule a peer to peer conversation. eviCore believes that physician – patient communications are essential to delivering quality care, consequently only referring physicians are allowed the opportunity to discuss case specific determinations with our medical directors and genetic counselors. eviCore will not discuss a case determination directly with a patient.

How do I request copies of utilization review guidelines?

To request copies of utilization review criteria, please complete this form and submit the request via email to reqcriteria@evicore.com or fax it to 1-866-699-8160, Attention: Request for Criteria.