Health Plans | Utilization Management Gastroenterology

eviCore’s Gastroenterology solution is a unique and comprehensive management approach that helps improve patient outcomes and control costs by promoting appropriate evidence-based use of endoscopic procedures via utilization management, a rigorous colorectal cancer screening advocacy program, and site-of-care redirection to high-value facilities where appropriate. With its link to our eviCore OnConnectSM Oncology solution, this program can manage a member from outreach for colorectal cancer screening, to testing and diagnosis of cancer, to scheduling with an oncologist or radiation oncologist when necessary—while helping to support the patient’s well-being every step of the way.

Services Covered

eviCore’s Gastroenterology solution covers the following services:

  • Upper Gastrointestinal Tract Endoscopies: Esophagogastroduodenoscopy (EGD) and Capsule Endoscopy
  • Lower Gastrointestinal Tract Endoscopies: Colonoscopy
  • Monitored Anesthesia Care (MAC)

Frequently Asked Questions

How does eviCore provide utilization management for upper and lower endoscopy?
eviCore has developed the industry’s most authoritative and comprehensive guidelines for the management of endoscopy procedures. Utilizing our staff of 12 board-certified gastroenterologists dedicated to our Gastroenterology Solution, we curate the most up-to-date published and peer-reviewed literature and society-endorsed guidance, and translate this information into our proprietary evidence-based guidelines. Medical necessity determinations and peer-to-peer consultations are completed exclusively by our gastroenterology specialists, providing true-peer interactions to providers and maintaining a record of demonstrated value with low abrasion. In addition, eviCore’s substantial presence in the medical benefit management market allows us to leverage our enterprise’s operational and technical infrastructure to meet market demand at unparalleled scale.
How does the colorectal cancer screening program work?
The eviCore Consumer Engagement unit directly reaches out to our clients’ members to encourage participation in colorectal cancer screening. We encourage members to complete either an at-home fecal immunochemical test (FIT) or a screening colonoscopy, as appropriate for their individual colorectal cancer risk. Our success in getting members to complete these procedures can then support our clients’ efforts to enhance their STAR or HEDIS ratings. Patients and their providers are notified of positive FIT results and advised to follow-up with appropriate next-level diagnostic testing, such as a colonoscopy.
What is site-of-care redirection?
eviCore applies evidence-based clinical guidelines to assess medical necessity for hospital outpatient-based procedures and redirects to accessible, high-quality certified ambulatory surgical centers, when appropriate.

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