Health Plans | Utilization Management Radiology

eviCore’s Radiology solution delivers cost savings and improved patient outcomes by ensuring health plan members receive the appropriate test or treatment necessary for their individual case presentation or condition. As a result, eviCore helps reduce inappropriate utilization, unnecessary radiation exposure, and invasive procedures and thereby improves patient safety.  eviCore’s 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.

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

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

FAQs

HEALTH PLANS
What is included in the Radiology 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 more than 800 medical directors and 300 nurses 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.
  • Network Analysis - eviCore has an experienced, dedicated staff tasked with reviewing the adequacy, value, and performance of the client’s network to ensure it meets the current and future needs of members and clients.
  • Analytics and Reporting - eviCore utilizes a robust analytics platform that can provide customized reports to meet client's needs. eviCore’s data management and analytical architecture enhances our reporting capabilities and serves as the information and analytics platform for the enterprise and its clients.
How does eviCore interact with radiology patients?

eviCore interacts with radiology patients in two ways. First, 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. Second, when requests reach a final status, the patient receives a letter indicating whether the request has been approved or denied.

What types of radiology procedures require prior authorization?

The diagnostic exams requiring prior authorization generally include the following procedures*:

  • 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
    - Nuclear cardiac imaging
  • Primary Imaging:
    - OB ultrasound
    - Diagnostic ultrasound (non-Ob)

*prior authorization of certain procedures can vary by health plan.

In some instances repeat exams for condition treatment or management will require prior authorization. Please check directly with your health plan for specific requirements or contact eviCore’s Customer Service at (800) 918-8924.

What additional tools are available as add-on programs to the Radiology solution?
  • 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 diagnostic imaging procedure. By presenting lower-cost, convenient, and high-quality options, SmartChoice empowers members to make more informed comparisons and choices.
  • Payment Integrity (Claims Studio): Our proprietary integrated system, Claims Studio, delivers incremental savings through a rigorous focus on accurate claims payment, which can be implemented as an extension of the client’s existing claims workflow. In the Claims Studio process, the claim is pended in the host system and 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.
  • Network Management: eviCore maintains a proprietary, robust national network of radiology facilities and associated medical professionals, including radiology centers that are part of a hospital and that are located inside private medical practices.
  • Privileging and Assessment Tool: eviCore offers a Privileging and Assessment program to help clients offer quality services through their existing networks by obtaining information about facility accreditation, staff training and experience, and equipment status and maintenance to determine which non-affiliated facilities are qualified to deliver specific imaging services.
PATIENTS
How do I obtain clinical certification for radiology 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

"eviCore has over 1,100 doctors, therapists and nurses from a variety of specialties. Their sole job is to ensure patients get the best possible care. Meet Dr. Scarborough, Chief of Radiology & SVP of Medical Affairs."

Dr. Scarborough

Chief of Radiology & SVP of Medical Affairs