Frequently Asked Questions: Evolent Oncology and Radiation Oncology Quality Management Program
Who is Evolent?
Evolent (formerly New Century Health) is a comprehensive oncology and radiation oncology quality management company whose goal is to apply evidence-based treatment to the delivery of oncology and radiation oncology care.
What is the Oncology Quality Management Program?
The Oncology Quality Management Program provides prior authorization management for your oncology and radiation oncology requests. 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, 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 in-service 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 oncologists and radiation oncologists
- Support staff with dedicated provider solutions representatives available to assist
How do I contact Evolent authorization support?
Call 1-888-999-7713 (medical oncology - option 2; radiation oncology - option 3). 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, 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 medical oncology medications or radiation oncology 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
(medical oncology – option 2; radiation oncology - option 3)
What is the turn-around time (TAT) for processing prior authorization requests?
Request Type | Medicare | Exchange |
Pharmacy Part D | Standard: Within 72 hours Expedited: Within 24 hours | Standard: Within 24 hours Expedited: Within 24 hours |
Medical Part B | Standard: Within 72 hours Expedited: Within 24 hours | Standard: Within 7 calendar days Expedited: Within 72 hours |
Medical Services | Standard: Within 14 calendar days Expedited: Within 72 hours | Standard: Within 7 calendar days Expedited: Within 72 hours |
What drugs require prior authorization?
The Oncology Quality Management Program, administered by Evolent, requires prior authorization management for Infused, injectable and oral chemotherapy, hormonal therapeutic treatment, supportive agents, and symptom management medications and radiation oncology services for members with a diagnosis code included in the following range:
- Cancer = C00 – D09, D37-D44, E34.0
- Hematology Diagnosis = D45-D49, D59.10-D59.19, D61.81, D61.82, D63.0, D63.8, D64.2-D64.3, D64.81, D64.89, D64.9, D68.59, D69.3, D69.41, D69.59, D69.6, D69.8, D69.9, D70.1-D70.9, D72.8, D72.9, D73.81, D73.9, D75.1, D75.81, D75.82
- N&V = R11
Which specialties are included in the Oncology Quality Management Program?
Gynecologic oncology, hematology, medical oncology, neuro-oncology, surgical oncology, urology, and radiation oncology will submit their prior authorizations through Evolent.
Who reviews radiation oncology requests?
Evolent medical reviewers are licensed oncologists and radiation oncologists 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 2 for medical oncology and option 3 for radiation oncology.
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). It is valid for the duration indicated on the Medication Request Authorization or Service Request Authorization (SRA).
Which place(s) of service are included in this program?
Physician’s office, in an outpatient hospital or ambulatory setting.
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, 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, 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.