Evolent

Delaware First Health has contracted with Evolent, for radiology benefit management.

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.

Delaware First Health oversees the Evolent program and is responsible for claims adjudication. Evolent manages non-emergent outpatient imaging/radiology services through contractual relationships with Delaware First Health.

Prior authorization is required for the following outpatient radiology procedures:

• CT/CTA/CCTA
• MRI/MRA
• PET Scan

The following services do not require authorization through Evolent:

• Inpatient advanced radiology services
• Observation setting advanced radiology services
• Emergency Room radiology services

Cardiac Solutions

Delaware First Health in collaboration with Evolent Magellan, will launch a cardiac imaging program to promote health care quality for patients with possible cardiac disease.

Under this program, prior authorization will be 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.

In addition to the other procedures that currently require prior authorization for members, prior authorization will be required for the following cardiac procedures:

• Myocardial Perfusion Imaging (MPI)
• MUGA Scan
• Echocardiography
• Stress Echocardiography
• Left heart catherization
• Implantables

Intervention Pain Management

Evolent manages non-emergent outpatient prior authorizations for Intervention Pain Management (IPM) procedures for Delaware First Health. 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 Injections or Blocks
• Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)
• Sacroiliac Join Injections

Note: separate prior authorization number is required for each procedure ordered above. 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 is still required through Delaware First Health.

The following services do not require authorization through Evolent:

• Inpatient advanced radiology services
• Observation setting advanced radiology services
• Emergency Room radiology services

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.

Go to the Evolent website for more information.