Radiology: Overview

eviCore’s Radiology benefit management solution reduces inappropriate utilization, decreases inefficiency and waste, and increases quality in diagnostic imaging by utilizing evidence-based criteria, including medical society standards, as well as up-to-date peer-reviewed medical literature.

  
 
  

Everyone benefits through better outcomes

  • Plans

    eviCore’s Radiology benefit management solution reduces the administrative burden for our clients, provides cost savings through the reduction of inappropriate utilization, and increases the quality of treatment the members receive.

  • Providers

    eviCore’s Radiology benefit management solution interacts with providers during implementation and then ongoing to render support and educational resources as well as obtain feedback for program improvements. In addition, we can assist risk-bearing providers with key innovative features such as our Clinical Decision Support system.

  • Patients

    eviCore’s Radiology benefit management solution improves patient safety by reducing unnecessary radiation exposure, medically inappropriate use of intravenous contrast agents, and the need for additional procedures.

  

Criteria & Easy Approval Process: Leading To Better Decisions

Nurse Review MD Review Peer to Peer Predictive Intelligence and Clinical Decision Support Appropriate Decision Web Phone Fax Methods of Intake REAL-TIME DECISION
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Educational Tools

Here you’ll find all the resources, tools, and links to know more about eviCore’s Radiology solution.​

  

The more we know, the better the outcome

A list of the most common Radiology queries are provided below. For more detailed information, visit the Contact Us page.
Health Plans
What is included in the Radiology solution?
  • Clinical Review - eviCore uses cutting edge technology including our proprietary predictive intelligence and clinical decision support to assist in the clinical review process. Additionally, our experienced team of more than 450 nurses and 190 medical directors ensure that members receive the most clinically appropriate decisions.
  • Provider Education - We interact with providers during implementation and on an ongoing basis to render support and educational resources, as well as obtain feedback for solution improvements.
  • Network Analysis - eviCore has an experienced, dedicated staff tasked with reviewing the adequacy, value, and performance of the client’s network to ensure it meets the current and future needs of members and clients.
  • Analytics and Reporting - eviCore utilizes a robust analytics platform that can provide customized reports to meet client's needs. eviCore’s reporting enhances our data management and analytical architecture to create a present and future solution that serves as the information and analytics platform for the enterprise and its clients.
How does eviCore interact with radiology patients?

eviCore’s innovative SmartChoiceSM​ program serves as a patient outreach service to educate health plan members on available options for their diagnostic imaging procedure locations. By presenting lower-cost, convenient, and high-quality options, SmartChoiceSM​​ empowers members to make more informed comparisons and choices. Additionally, patients can verify the status of their cases by contacting eviCore’s Customer Service at (800) 918-8924.

What types of radiology procedures require clinical certification (pre-certification)?

The diagnostic exams requiring clinical certification generally include the following procedures*:

  • Advanced Imaging:
    - Magnetic resonance imaging (MRI)
    - Magnetic resonance angiograms (MRAs)
    - Positron emission tomography (PET) scans
    - Positron emission tomography –computed tomography (PET-CT)
    - Computerized tomography (CT) scans
    - Computed tomography angiography (CTA) scans
    - Nuclear medicine
    - Nuclear cardiac imaging
  • Primary Imaging:
    - OB ultrasound
    - Diagnostic ultrasound (non-Ob)

*Clinical certification of certain procedures can vary by health plan.

In some instances repeat exams for condition treatment or management will require certification. Please check directly with your health plan for specific requirements or contact eviCore’s Customer Service at (800) 918-8924.

What additional tools are available as add-on programs to the Radiology solution?
  • Consumer Engagement (SmartChoiceSM): eviCore’s innovative SmartChoice program serves as a patient outreach service to educate health plan members on available options for their diagnostic imaging procedure locations. By presenting lower-cost, convenient, and high-quality options, SmartChoice empowers members to make more informed comparisons and choices.
  • Payment Integrity (Claims StudioSM): Our proprietary system, Claims StudioSM, delivers incremental savings through a resolute focus on accurate claims payment which can be an extension of the client’s existing claims workflow. In the Claims Studio process, the claim is pended in the host system, sent to eviCore where it is adjudicated with eviCore’s proprietary claims engine, and then returned to the host system for payment all in the same day.
  • Network Management: eviCore has a proprietary, robust national network of radiology facilities and associated medical professionals that we work with, including radiology centers that are part of a hospital and that are located inside private medical practices.
  • Privileging and Assessment Tool: eviCore offers a Privileging and Assessment program to help clients offer quality services through their existing networks by obtaining information about facility accreditation, staff training and experience, and equipment status and maintenance to determine which non-affiliated facilities are qualified to delivery specific imaging services.
Patients
How do I obtain clinical certification?

The physician, or their designated office staff, managing your treatment plan must obtain the authorizations necessary for your exams.

How do I know when my test has been authorized?

The Clinical Certification Unit will provide you and your physician with the authorization information.

What if my exam does not get approved?

If the requested exam is denied, eviCore will notify both you and your physician and provide you with detailed appeal instructions.

Where do I go to get my diagnosis imaging exam?

Contact our Customer Service Unit at (800) 918-8924. We will provide you with quality alternatives close to your home or office.