Musculoskeletal: Overview

eviCore’s intelligent care management suite of musculoskeletal solutions focuses on a patient-centered approach, promotes evidence-based medicine, and ensures the best outcome at the appropriate cost. Core components of these solutions include clinical management and organic evidence-based guidelines.​

Learn more about eviCore's Spine corePath Program

  
 
  

Everyone benefits through better outcomes

  • Plans

    Our Musculoskeletal solutions create an unparalleled partnership with each client health plan in an effort to improve population health. These solutions are collaboratively tailored and uniquely designed to deliver the right treatment with the right provider at the right time. Through our portfolio of Musculoskeletal solutions, we help our health plans maximize the value of their network by promoting clinically appropriate, evidence-based guidelines, and cost-effective care.

  • Providers

    Our Musculoskeletal solutions partner with participating network providers to enable the coordination of care among patient, provider, and plan care teams from symptom onset, all the way through to appropriate treatment, and finally recovery. Providing medically necessary care, as defined by evidence-based medicine, offers global value to those stakeholders.

  • Patients

    Our Musculoskeletal solutions deliver a patient-centered approach that promotes evidence-based clinical decisions to ensure the best outcomes at the appropriate cost. Our strategy and execution include the education and engagement of all stakeholders, which is imperative to successfully coordinating care, building a patient acumen of treatment options, and concentrating on providing quality patient outcomes.

  

Criteria & Easy Approval Process: Leading To Better Decisions

Nurse/ Specialist Review MD Review Peer to Peer Predictive Intelligence and Clinical Decision Support Multiple procedure service requests at the same time Appropriate Decision Web Phone Fax Methods of Intake REAL-TIME DECISION
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The more we know, the better the outcome

A list of the most common Musculoskeletal queries are provided below. For more detailed information, visit the Contact Us page.
Patients
What is the role of eviCore healthcare?

eviCore healthcare’s main focus is to improve the quality of patient care.

What is the relationship between my health plan and eviCore healthcare?

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

What is the best way to submit a pre-authorization?

The fastest way for physicians to achieve a medical necessity determination is by visiting eviCore healthcare’s website at eviCore.com, prior to the date of service requiring authorization. Our Web portal is accessible for pre-authorizations 24 hours a day, 7 days a week. Additionally, pre-authorizations can be submitted by phone and fax.

Providers
What is the best way to submit a pre-authorization?

The fastest way for physicians to achieve a medical necessity determination is by visiting eviCore healthcare’s website at eviCore.com, prior to the date of service requiring authorization. Our Web portal is accessible for pre-authorizations 24 hours a day, 7 days a week. Additionally, pre-authorizations can be submitted by phone and fax.

Is registration required at eviCore healthcare’s website?

You will be required to log-in prior to obtaining authorizations on the Web.

Will urgent requests be accepted?

Yes. Urgent requests will be accepted and a determination expedited if clinically required.

How will I be notified of a determination?

If the prior authorization request was submitted via Web portal then an email notification will be sent to the email address registered on the portal. If the prior authorization request is submitted via fax, then a faxed determination letter will be sent to the provider. Patients are sent a determination letter by mail.

What is the turnaround time for a determination on a prior authorization request?

For cases whose decision is reached after clinical review, the provider will be notified with verbal or written communication according to applicable regulation and law. Please refer to the Health Plan resource page for additional information.

What are my options when a prior authorization request is denied?

The office can contact eviCore to request a peer-to-peer discussion. When there is a request for a peer-to-peer consultation, we will make an effort to transfer the call immediately to an available eviCore medical director. When a Medical Director is not available, we will offer a scheduled call-back time that is convenient for the practice. Please refer to the health plan resource page for additional information.

How long does my patient’s approval last?

eviCore healthcare communicates the expiration date in the approval notification for each case. Please refer to the Health Plan resource page for additional information.

Where do I submit claims?

Submit claims directly to the Health Plan.