Evolent
Coordinated Care has contracted with Evolent, for radiology benefit management, cardiac solutions and interventional pain management.
Radiology Services
The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.
Coordinated Care oversees the Evolent program and is responsible for claims adjudication. Evolent manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.
Prior authorization is required for the following outpatient radiology procedures:
- CT/CTA/CCTA
- MRI/MRA
- PET Scan
Cardiac Solutions
Evolent also reviews cardiac imaging studies to promote health care quality for patients with possible cardiac disease. Under this program, prior authorization is required for certain cardiac studies to determine if the cardiac test or procedure is the most appropriate next step in a patient’s diagnosis or treatment, and to recommend an alternate approach when indicated. By supporting the most efficient diagnosis and management of cardiac disease, Evolent addresses unnecessary procedures and promotes the least invasive, most medically appropriate approach.
Evolent has developed proprietary utilization management guidelines for these cardiac modalities. These consensus-based guidelines draw on current literature, American College of Cardiology (ACC) appropriateness criteria, recommendations from the American Heart Association, and input from our Cardiac Advisory Board and other experts. Evolent's guidelines are transparent and available throughout their programs. Evolent also includes references to the Choosing Wisely campaign by the American Board of Internal Medicine (ABIM) Foundation, which provides specialty society considerations for the selection of appropriate tests.
Evolent manages prior authorization for the following cardiac procedures:
- Myocardial Perfusion Imaging (MPI)
- MUGA Scan
- Echocardiography
- Stress Echocardiography
- Left Heart Catherization
- Implantable Devices
Interventional Pain Management
Evolent manages non-emergent outpatient prior authorizations for Interventional Pain Management (IPM) procedures. It is the responsibility of the ordering physician to obtain authorization for all IPM procedures outlined below. Outpatient IPM procedures requiring prior authorization include:
- Spinal Epidural Injections
- Paravertebral Facet Joint Injections or Blocks
- Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)
- Sacroiliac Joint Injections
Key Provision:
Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim. A separate prior authorization number is required for each procedure ordered.
Prior authorization is not required through Evolent for services performed in the emergency department, on an inpatient basis or in conjunction with a surgery. Prior authorization and/or notification of admission in those instances is required through the health plan.
To obtain authorization through Evolent or for more information, visit Evolent's web site.