Health Plans | Utilization Management Laboratory Management

eviCore healthcare’s (eviCore’s) Laboratory Management solution utilizes test-specific current medical policies and prior authorization guidelines to improve the quality of care and reduce genetic-testing costs. This solution helps ensure that our health plan clients pay the right amount, on the right claim, for the appropriate test. The core components of this solution are medical policy, prior authorization, payment integrity, and lab network.

Medical Policy (Clinical Guidelines)

Medical policy is the foundation for all of eviCore’s solutions, but perhaps even more so for the Laboratory Management solution. eviCore created proprietary evidence-based clinical guidelines built on independent technology assessments, nationally recognized professional guidelines, and peer-reviewed criteria. Our policy library is the most comprehensive in the market, with policies covering more than 500 molecular and genomic tests.

Policy Updates

The eviCore Laboratory Management Team applies a surveillance process that continually searches applicable genetic and molecular industry literature for new tests and applicable evidence. We review and update clinical guidelines when new evidence-based literature is published or a new lab test is developed that would result in material change to one of our clinical pathways. All policies are reviewed at least annually, and updates are typically provided twice a year. eviCore’s Laboratory Management clients typically adopt the majority of eviCore’s Laboratory Management policies, but client-specific customizations are possible at implementation. The client-approved molecular and genetic clinical guidelines will be available for ordering providers on our clients’ Web portal once the Laboratory Management solution has been implemented.

Frequently Asked Questions

How are policies created and updated?

Laboratory Management policies are written internally by expert staff and reviewed by internal and external medical advisory boards. Policies are reviewed at least semi-annually but are updated more often if significant new evidence is identified. eviCore considers peer-reviewed publications and guidelines from all major professional societies when creating clinical policies. eviCore’s Lab Policy book is the largest in the market, including policies that cover more than 500 genetic tests.

What claims are subject to claims review?

Technically, all claims for CPT codes that are in scope are subject to claims review. eviCore reviews the claim to make sure it received any necessary prior authorization. In addition, eviCore automatically applies more than 44,000 lab-specific claim rules to ensure appropriate reimbursement for medically necessary tests. The vast majority of these rules apply to low-cost, high-volume tests that are not as amenable to prior authorization.

How does eviCore handle large gene panels?

Most panels require prior authorization. When panels are billed with individual codes for the genes in a panel, eviCore reviews the medical necessity of each gene within a panel and typically only prior authorizes and recommends reimbursement for those genes that are medically necessary. In addition, many panels now have a panel-specific CPT code, but some labs are still billing with multiple stacked CPT codes. eviCore helps ensure our clients only pay claims that appropriately coded.

What if I have a question about a prior authorization result?

Both the referring and rendering provider, if known, will receive a copy of the determination correspondence for each case review. Providers can contact eviCore at the number provided on the case correspondence to discuss a prior-authorization decision or schedule a peer-to-peer conversation. eviCore believes that physician-patient communications are essential to the delivery of quality care; consequently only providers are allowed the opportunity to discuss case-specific determinations with our medical directors and genetic counselors. eviCore will not discuss a case determination directly with a patient.

How do I request copies of utilization review guidelines?
To request copies of utilization-review criteria, please complete this form and submit the request via email to reqcriteria@evicore.com or fax it to 1-866-699-8160, Attention: Request for Criteria.