Health Plans | Utilization Management Cardiovascular

eviCore’s Cardiovascular solution delivers cost savings and improved patient outcomes by ensuring health plan members receive the appropriate test or treatment necessary for their individual cardiovascular case presentation or condition. As a result, eviCore can reduce inappropriate utilization, unnecessary radiation exposure, and invasive procedures that can jeopardize patient safety and outcomes. eviCore’s approach is not to deny care that is needed, but to help providers and patients identify the most appropriate testing and treatment options to ensure safety and maximize value.

Services Covered Cardiology Services eviCore Covers

Services Covered

  • Stress testing
    • Myocardial perfusion imaging (SPECT & PET)
    • Stress echocardiography
  • Cardiac CT and MRI
  • Echocardiography (post-service only)
    • Transthoracic (TTE)
    • Transesophageal (TEE)
  • Diagnostic heart catheterization
  • Pacemakers
  • Implantable cardioverter defibrillator (ICD)
  • Vascular interventions 
  • Percutaneous coronary intervention (post-service only)

FAQs What types of cardiovascular procedures require prior authorization?

The procedures requiring clinical certification generally include the following:*

Advanced Imaging and Diagnostic Services:

  - Stress testing

- Myocardial perfusion imaging (SPECT and PET)

  - Stress echocardiography

- Echocardiography: transthoracic and transesophageal

- Diagnostic heart catheterization

  - Cardiac CT and MRI

Implantable Device Services:

  - Pacemakers

- Implantable cardioverter defibrillator (ICD)

*The requirements for clinical certification of specific procedures can vary by health plan.

What is included in the Cardiovascular 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 nurses and board-certified cardiologists ensures 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.
  • Analytics and Reporting - We utilize a robust analytics platform that can provide customized reports to meet our client’s data management 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.
What additional tools are available as add-on programs to the Cardiovascular solution?
  • Payment Integrity (Claims Studio): Our proprietary system, Claims Studio, delivers incremental savings through a rigorous focus on accurate claims payment that can be implemented as an extension of the client’s existing claims workflow. With Claims StudioSM, the claim is pended in the host system and then 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.
  • Consumer Engagement (SmartChoice): eviCore’s innovative SmartChoice program serves as a patient outreach service to educate health plan members on available options for the location of their advanced cardiac diagnostic imaging procedure. By presenting lower-cost, convenient, and high-quality options, SmartChoice empowers members to make more informed comparisons and choices.
How do I obtain clinical certification for cardiology tests?

The physician, or designated office staff, managing your treatment plan must obtain the authorizations necessary for any testing or treatment you may need.

How do I know when my test has been authorized?

You will receive a letter in the mail and your physician will receive a letter via fax communicating this information.

What if my tests do not get approved?

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

clinical expertise

As a practicing cardiologist, I was drawn to the human element of eviCore. I am there to listen to and understand the provider's assessment, and to make sure the patient is getting what they need. It is my goal to continue to engage and establish relationships with providers to make the healthcare system work better, and to improve patients' experience on their journey to good health.

Dr. Julius Torelli

Chief of Cardiology Programs

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