Frequently Asked Questions: Evolent Cardiology Management Program
Who is Evolent?
Evolent (formerly New Century Health) is a comprehensive cardiology quality management company whose goal is to apply evidence-based treatment to the delivery of cardiology care.
What is the Cardiology Quality Management Program?
The Cardiology Quality Management Program provides prior authorization management for invasive cardiology services rendered in a physician’s office, outpatient hospital, and ambulatory or inpatient setting (planned professional services only). The program emphasizes and supports the selection of preferred pathways for patient care and authorizations are administered by Evolent.
What members are included in this program?
Ambetter from Meridian Michigan, MeridianComplete, Meridian Medicaid Michigan, and Wellcare Complete by Allwell Michigan, members 18 years of age and older.
When will the program begin?
The program will begin June 1, 2024.
How can a physician’s office request training for this program?
A provider solution specialist will contact you to schedule an introductory meeting and training. If you have any questions prior to the introductory meeting, please contact Evolent at 1.888.999.7713, option 6 or email providertraining@newcenturyhealth.com.
What are some key features of the program?
Evolent offers providers:
- Real-time authorizations for treatment care pathways
- Real-time status of authorization requests
- Quick turnaround on authorization requests
- Eligibility verification
- Physician discussions with cardiologists
- Support staff with dedicated provider solutions representatives available to assist
How do I contact Evolent authorization support?
Call 1-888-999-7713 (option 1). Staff is available Monday-Friday 7:00 a.m. to 7:00 p.m. CST.
What is the transition of care process?
Ambetter from Meridian Michigan, MeridianComplete, Meridian Medicaid Michigan, and Wellcare Complete by Allwell Michigan approvals issued before June 1, 2024, are effective until the authorization end date. Starting June 1, 2024, please submit prior authorization requests to Evolent.
Who is responsible for obtaining prior authorization?
The physician organization ordering cardiology services must request prior authorization through Evolent.
How do I obtain prior authorization?
By submitting requests to Evolent:
- Online my.newcenturyhealth.com.
- Via telephone at 1-888-999-7713 (option 1)
What is the turn-around time (TAT) for processing prior authorization requests?
Request Type | Medicaid and Medicare | Exchange |
|---|---|---|
Medical Services | Standard: Within 14 calendar days Expedited: Within 72 hours | Standard: Within 7 calendar days Expedited: Within 72 hours |
What services / specialists are included in the program?
The program will apply to all specialties for the following invasive cardiovascular services only:
- Cardiac Catheterization and Intervention
- Electrophysiology
- Vascular Radiology and Intervention
- Cardiac Surgery
- Vascular Surgery
Who reviews cardiology requests?
Evolent medical reviewers are licensed cardiologists using nationally recognized clinical guidelines when performing reviews. Clinical guidelines are available at my.newcenturyhealth.com or by contacting Evolent at 1.888.999.7713, option 1.
What happens if the authorization request does not meet guidelines?
If the request does not meet evidence-based treatment guidelines, Evolent may request additional information or initiate a physician discussion with the requesting provider.
What will the Evolent authorization number look like, and how long is it valid?
The Evolent authorization will start with “AR” followed by at least four digits (e.g., AR1000) and be valid for the 60-day duration indicated on the Service Request Authorization (SRA).
Which place(s) of service are included in this program?
Cardiology services rendered in a physician’s office, outpatient hospital, ambulatory, or inpatient setting (planned professional services only).
Does prior authorization guarantee payment?
No. Prior authorization does not guarantee payment for services. Payment of claims is dependent on eligibility, covered benefits, provider contracts, and correct coding and billing practices. For specific details, please refer to your Provider Manual.
Who is responsible for responding to grievances and appeals?
Ambetter from Meridian Michigan, MeridianComplete, Meridian Medicaid Michigan, and Wellcare Complete by Allwell Michigan will maintain the grievance and appeal processes.
What will happen if the physician does not request and obtain an authorization?
If authorization is not obtained, Ambetter from Meridian Michigan, MeridianComplete, Meridian Medicaid Michigan, and Wellcare Complete by Allwell Michigan may deny payment for the relevant services. Members may not be held responsible or billed for denied charges/services. Providers may only be able to collect the applicable cost share amount directly from the member.