Durable Medical Equipment
Durable Medical Equipment (DME) demand and utilization is on the rise, and now more than ever, health plans need a sense of trust that the most appropriate DME is being delivered to their members. DME often represents a fragmented, uncoordinated area of management, which can drive up health plan costs. It is also imperative that members receive the right equipment, at the right time, and at the right place—both for ongoing management of chronic conditions and for recovery from acute and/or post-acute episodes of care.
Durable Medical Equipment Management
As a market leader in comprehensive medical benefits management, Evernorth Care at Home provides our clients with an immediate savings opportunity through our Durable Medical Equipment solution. Our enhanced utilization management and care coordination capabilities help ensure that patients receive clinically appropriate equipment to create optimal health outcomes. Additionally, we also offer a national network of high-quality DME providers and can manage DME provider relationships on behalf of our health plan clients. There are 14 categories of DME we provide utilization management for (respiratory, mobility, cardiac, skin and wound care, MSK, footwear, home care, supplies, communication, diabetes, infusion pumps, stimulators, artificial kidney machines and miscellaneous codes). Each category of DME has subcategories which each of the over 1400 DME codes we provide authorization for fall into. If providers use our web portal to submit authorization requests, they have an opportunity to get real time approval through our clinical pathways available to all providers. Evernorth Care at Home is building proprietary clinical guidelines for DME which will eliminate our dependence on evidence-based guidance solutions (MCG and IQ).
Member Experience
94% of patients surveyed were satisfied with DME services and equipment received. Over 90% of DME cases were reviewed within 24 hours which is important especially for members needing equipment upon hospital or facility discharge especially when it comes to things like Oxygen. If there is a delay in DME delivery it can easily lead to potentially preventable readmission to the hospital something we want to avoid.
1. Utilization Management
Utilization Management, performed by clinicians who possess a deep understanding of DME. Evernorth Care at Home strategically works with our health plan customers to select which equipment and codes to manage, and those for which we require prior authorization, to maximize the program’s effectiveness for each health plan client, toward the goal of achieving optimal cost and effectiveness for their members.
2. Individualized care coordination
Individualized care coordination, to ensure that patients receive their supplies and understand how to use the equipment.
3. Network management
Network management, where we oversee provider performance on behalf of health plan clients. Note- While payers can elect to leverage their own networks, have found that providing DME Management as an end-to-end solution improves outcomes for members and increases savings for our clients.
Guaranteed savings.
Our DME solution incorporates a risk-based funding model, in which Evernorth assumes financial responsibility for the total delegated medical spend.
Clinical and operational expertise in DME.
Our clinicians and physicians have deep knowledge of the durable medical equipment space. We have a dedicated complex/high-dollar DME review team with PM&R board certified physicians, proprietary DME clinical guidelines, and coding review expertise. Our clinicians have years of experience navigating state and federal mandates. The DME team recently added a pediatrician to review cases for children as they come in and our Doctors work 7 days a week in this space which allows this team to process DME and HH cases every single day including weekends.
Personalized member engagement.
We perform service validation calls to each member receiving DME and can help to quickly identify and solve issues with equipment, education, adherence, continuity of care, and other needs.
Frequently Asked Questions
EviCore healthcare (EviCore) is an independent specialty medical benefits management company that provides utilization management services.
Eligibility and benefits should be verified with the Health Plan before every service request. Providers are encouraged to check online.
Once all required information is submitted to eviCore, outreach will be made to providers with a determination within 1 - 2 business days for routine requests.
- Verbal outreach is made to requesting provider
- Letter is faxed to requesting provider and mailed to member
- Authorization details are available on the eviCore Web Portal and may be printed on demand
Providers can confirm that the Prior Authorization is valid by logging into the EviCore Post-Acute Care Web Portal.
Requests for the denial rationale may be sent to EviCore at: DENCRationaleRequests@evicore.com. EviCore will email the rationale within 4 hours of receipt. If the request is received after 5pm CST M-F, EviCore will respond by 9am CST the next day, Tues-Sat. If the request is received after 4pm CST Sat, EviCore will respond by 9am CST the next business day. To eliminate time constraints by e-mail, providers may call eviCore at 877-791-4104 to request the denial rationale to be dictated by phone.
Once a service has been denied, members and providers must file an appeal to have the request re-reviewed. Appeal requests should be submitted to The Health Plan via fax at 740-699-6163 or phone at 877-847-7907. The Health Plan will make the final determination and send out the appeal notification.
Members requesting to appeal the EviCore decision to end skilled care in a SNF or HHC agency should follow the Quality Improvement Organization (QIO) process as outlined on the NOMNC.
All claims will continue to be filed directly to the Health Plan.
For program related questions or concerns, please email: clientservices@evicore.com
For more information and reference documents, please visit our provider resource site: https://www.evicore.com/resources/healthplan
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