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Health Plans | Utilization Management

Radiology

Did you know up to one-third of CTs and MRIs may be deemed unnecessary and carry radiation risks for patients? 1 And that 20%-50% of diagnostic imaging exams may be considered redundant? 2 EviCore’s Radiology solution ensures health plan members receive the most appropriate test or treatment necessary for their individual medical needs, delivering cost savings, reducing inappropriate utilization and improving patient outcomes. Our approach is not to deny care that is needed but rather to redirect providers and patients to more appropriate testing and treatment options, which helps ensure safety and maximize value.

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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

 

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Primary Imaging

  • Non-OB ultrasound – including head & neck, pediatric, breast, abdomen & retroperitoneum, extremity, arterial & venous, and gynecological
  • OB ultrasound – including obstetrical ultrasounds and fetal echocardiography

 

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Clinical Guidelines

Our evidence-based radiology clinical guidelines are based on guidelines and criteria from major national and international associations and societies. We also use peer-reviewed literature and major treatises, as well as input from health plans and practicing academic and community-based physicians. In addition, we support Choosing Wisely, an initiative to reduce the overuse of diagnostic tests that are of marginal or no value, or whose risks are greater than their benefits, which is maintained by the American Board of Internal Medicine (ABIM) Foundation and many national physician organizations. 

 

 

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Network

Our nationwide advanced imaging network includes providers of imaging services in specific locations as well as freestanding facilities. Our network of quality providers offers an attractive option for health plans seeking to better manage radiology benefits.

 

 

 

 

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Patient Engagement

Our innovative SmartChoice program serves as a patient-outreach service that educates health plan members on available locations for advanced imaging procedures. By presenting convenient, lower-cost, high-quality options, SmartChoice empowers members to make more informed comparisons and choices. 

 

 

 

 

Frequently Asked Questions

  • Medical Necessity Review – Our experienced team of medical directors and specialized nurses ensures providers and their patients receive the most clinically appropriate decisions. We leverage cutting-edge technology, including our proprietary predictive intelligence and clinical decision support, to assist in the review process. 

  • Provider Education – We interact with providers during implementation and on an ongoing basis to offer support and educational resources, as well as obtain feedback for solution improvements.

  • Analytics and Reporting – Our robust data management and analytics platform provides customized reports to meet the specific needs of the health plans we serve.

First, patients receive a letter indicating whether their provider’s request is approved or denied. Second, our 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.

It varies by health plan but procedures typically requiring PA include:
Advanced Imaging:

  • Magnetic resonance imaging (MRI)
  • Magnetic resonance angiogram (MRA)
  • Positron emission tomography (PET) scan
  • Computerized tomography (CT) scan
  • Positron emission tomography–computed tomography (PET-CT) scan
  • Computed tomography angiography (CTA) scan
  • Nuclear medicine
  • Nuclear cardiac imaging

Primary Imaging:

  • OB ultrasound
  • Non-OB diagnostic ultrasound (post-service only)

In some instances, repeat exams for condition treatment or management require PA. Please check with your health plan for specific requirements or contact our Customer Service at 1.800.918.8924.

  • Consumer Engagement (SmartChoice): This innovative patient-outreach service educates health plan members on available options for the location of their diagnostic imaging procedures. By presenting lower-cost, convenient, and high-quality options, SmartChoice empowers members to make more informed comparisons and choices.
  • Network Analysis: We review the adequacy, value, and performance of the health plan’s network to ensure it meets the current and future needs of the plan and its members.
  • Network Management: We maintain a robust national network of radiology facilities and associated medical professionals, including hospital-affiliated radiology centers, as well as those located inside private medical practices.

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

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

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

Radiology Insights

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