Provider FAQs

Preauthorization Update for Musculoskeletal (MSK) and Interventional Pain Management (IPM)

Below you'll find answers to the questions we get asked the most.

The MSK program is designed to improve quality and manage the utilization of IPM procedures and musculoskeletal surgeries.  

  • Musculoskeletal surgeries are a leading cost of health care spending trends.
  • Variations in member care exist across all areas of surgery (care prior to surgery, type of surgery, surgical techniques and tools and post-op care)
  • Diagnostic imaging advancements have increased diagnoses and surgical intervention aligning with these diagnoses rather than member symptoms.
  • Medical device companies marketing directly to consumers.
  • Surgeries are occurring too soon leading to the need for additional or revision surgeries.

Outpatient IPM:

A separate prior authorization number is required for each procedure ordered. A series of injections will not be approved.

  • Spinal Epidural Injections 
  • Paravertebral Facet Joint Injections or Blocks
  • Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis) 

Outpatient and Inpatient Spine Surgeries:

  • Lumbar Microdiscectomy
  • Lumbar Decompression (include laminotomy, laminectomy, facetectomy, foraminotomy)
  • Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single and Multiple Levels
  • Lumbar Artificial Disc Replacement -Single and Multiple Levels
  • Cervical Anterior Decompression with Fusion (ADCF) –Single and Multiple Levels 
  • Cervical Posterior Decompression with Fusion – Single and Multiple Levels
  • Cervical Anterior Decompression (without fusion)
  • Cervical Posterior Decompression (without fusion)
  • Cervical Artificial Disc Replacement – Single and Multiple Levels  

Evolent (formerly National Imaging Associates, Inc.) does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those listed above.

Evolent was selected to partner with us because of its clinically driven program designed to effectively manage quality and member safety, while ensuring appropriate utilization of resources for BCBSNE Medicare Advantage and Commercial membership.
The MSK program applies to BCBSNE Commercial and Medicare Advantage members and is managed through BCBSNE contractual relationships.
Implementation is Jan. 1, 2025, for Medicare Advantage plans. Commercial plans started Sept. 1, 2015.

Prior authorization is required through Evolent for the IPM procedures and MSK surgeries above.

BCBSNE prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery has met Evolent’s medical necessity criteria. Once an authorization has been obtained for the procedure/surgery, BCBSNE will reach out to the rendering provider to authorize the facility in which the procedure will be performed.

Procedures performed on or after Jan. 1, 2025 (Medicare Advantage) or Sept. 1, 2015 (Commercial), require prior authorization through Evolent. 
Yes. All non-emergent outpatient Interventional Pain Management (IPM) procedures are required to be prior authorized through Evolent. 
As a part of the Evolent clinical review process, actively practicing neurosurgeons (spine) will conduct the medical necessity reviews and determinations of musculoskeletal surgery cases.
Evolent’s medical necessity review and determination process is only for the authorization of the surgeon’s professional services and type of surgery being performed.
Providers submit prior authorization requests via the Evolent website (RadMD.com) or by calling Evolent at 1-800-424-4956.
 

To expedite the process, please have the following information ready before logging on to the Evolent website or calling the call center: 
(*denotes required information)

  • Name and office phone number of ordering physician*
  • Member name and ID number*
  • Requested surgery type*
  • CPT Codes
  • Name of facility where the surgery will be performed*
  • Anticipated date of surgery*  
  • Details justifying the surgical procedure*:
    • Clinical Diagnosis*
    • Date of onset of back pain or symptoms /Length of time member has had episode of pain*
    • Physician exam findings (including findings applicable to the requested services)
    • Diagnostic imaging results
    • Non-operative treatment modalities completed, date, duration of pain relief, and results (e.g., physical therapy, epidural injections, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication)

Please be prepared to provide the following information, if requested:

  • Clinical notes outlining type and onset of symptoms.
  • Length of time with pain/symptoms
  • Non-operative care modalities to treat pain and amount of pain relief.
  • Physical exam findings
  • Diagnostic Imaging results
  • Specialist reports/evaluation

No. Evolent will provide a list of surgery categories to choose from and the BCBSNE provider must select the most complex and invasive surgery being performed as the primary surgery. 
 
Example:  Lumbar Fusion

If the BCBSNE surgeon is planning a single level Lumbar Spine Fusion with decompression, the surgeon will select the single level fusion procedure. The surgeon does not need to request a separate authorization for the decompression procedure being performed as part of the Lumbar Fusion Surgery. This is included in the Lumbar Fusion request.  
 
Example: Laminectomy 

If the BCBSNE surgeon is planning a Laminectomy with a Microdiscectomy, the surgeon will select the Lumbar decompression procedure. The surgeon does not need to request a separate authorization for the Microdiscectomy procedure. 

If the BCBSNE surgeon is only performing a Microdiscectomy (CPT 63030 or 63035), the surgeon should select the Microdiscectomy only procedure


The intake process is designed to guide ordering providers to the correct primary surgery as additional CPT codes are entered. We recommend entering multiple codes (if applicable) to ensure the correct procedure type is selected.
Yes. The instrumentation (medical device), bone grafts, and bone marrow aspiration procedures commonly performed in conjunction with musculoskeletal surgeries are included in the authorization; however, the amount of instrumentation must align with the procedure authorized. 

Please have the following information available when initiating an authorization request: 

  • Clinical Diagnosis
  • Date of onset of back pain or symptoms /Length of time member has had episode of pain.
  • Physician exam findings (including findings applicable to the requested services)
  • Pain/Member Symptoms 
  • Diagnostic imaging results
  • Non-operative treatment modalities completed, date, duration of pain relief, and results (e.g., physical therapy, epidural injections, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication)

Generally, within 2 to 3 business days after receipt of request with full clinical documentation, a determination will be made. In certain cases, the review process can take longer if additional clinical information is required to make a determination.


The Evolent authorization number consists of alpha-numeric characters. In some cases, the provider may instead receive an Evolent tracking number (not the same as an authorization number) if the authorization request is not approved at the time of initial contact. Providers can use either of these numbers to track the status of their request online or through an Interactive Voice Response (IVR) telephone system.
You will receive a tracking number and Evolent will contact you to complete the process.
No, those requests will need to be called into Evolent’s call center for processing at 1-866-972-9642 for Commercial and 1-800-424-4956 for Medicare Advantage.
The authorization number is valid for 90 days from the date of request.
Yes, for Commercial plans.

No, for Medicare Advantage plans. 
An authorization number is not a guarantee of payment.  Authorizations are based on medical necessity and are contingent upon eligibility and benefits. Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. 

Evolent’s medical necessity review and determination is for the authorization of the surgeon’s professional services and type of surgery being performed.
It is important that physicians and office staff are familiar with prior authorization requirements. Claims for procedures above that have not been properly authorized will not be reimbursed. Providers should not schedule or perform these procedures without prior authorization.
Medicare Advantage - Authorizations can be obtained starting Jan. 1, 2025, for dates of service of Jan. 1, 2025, and beyond.
 
Commercial - Authorizations can be obtained starting Sept. 1, 2015, for dates of service of Sept. 1, 2015, and beyond. 

Evolent and BCBSNE work with the provider community on an ongoing basis to continue to educate providers.
Yes. Providers can check the status of authorization requests quickly and easily by going to the Evolent website at RadMD.com.

In the event of a prior authorization or claims payment denial, providers may appeal the decision through BCBSNE.  Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification.
Evolent asks where the surgery is being performed and the anticipated date of service. Providers should obtain prior authorization before scheduling the member and the facility or hospital admission.

Neurosurgeons and Orthopedic Surgeons are the key physicians impacted by this program.   

Procedures performed in the following settings are included in this program:

  • Hospital (Inpatient and Outpatient Settings)
  • Ambulatory Surgical Centers 
  • In Office

BCBSNE rendering providers/surgeons continue to send claims directly to BCBSNE.

Rendering providers/surgeons are encouraged to use EDI claims submission.

Rendering providers/surgeons should check claims status by logging into www.navinet.net or by phone at 1-888-505-2022.
Providers are asked to follow the appeal instructions on their non-authorization letter or Explanation of Benefits (EOB) notification.

Evolent defines medical necessity as services that:

  • Meets generally accepted standards of medical practice; be appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient evidence and professionally recognized standards;
  • Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;
  • Be appropriate to the intensity of service and level of setting;
  • Provide unique, essential, and appropriate information when used for diagnostic purposes;
  • Be the lowest cost alternative that effectively addresses and treats the medical problem; and rendered for the treatment or diagnosis of an injury or illness; and
  • Not furnished primarily for the convenience of the member, the attending physician, or other surgeon.
BCBSNE and Evolent share training and education materials with physicians and surgeons prior to the implementation. BCBSNE and Evolent also coordinate outreach and orientation for providers.

Clinical guidelines can be found on the Evolent website at RadMD.com. They are presented in a PDF file format that can easily be printed for future reference. Evolent’s clinical guidelines have been developed from practice experiences, literature reviews, specialty criteria sets and empirical data.

No. The BCBSNE member ID card does not contain any Evolent information on it and the member ID card will not change with the implementation of this MSK Program.
Once a denial determination has been made, if the provider has new or additional information to share, a reconsideration can be initiated by uploading via RadMD or faxing (using the case specific fax cover sheet) additional clinical information to support the request. A reconsideration must be initiated within Seven calendar days from the date of denial and prior to submitting a formal appeal.  

Medicare Advantage plans: Effective 8/5/2024, peer-to-peer discussions must be performed before a final determination has been made on the request. 

Medicare re-opens are only allowed if the request complies with the CMS definition of a re-open. Providers will continue to have the option to submit an appeal utilizing the health plan’s process. 

Evolent has a specialized clinical team focused on the MSK program. Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines. Providers can call 1-866-972-9642 (Commercial) or 1-800-424-4956 (Medicare Advantage) to initiate the peer-to-peer process. These discussions provide an opportunity to discuss the case and collaborate on the appropriate services for the member based on the clinical information provided.
If the user already has access to RadMD, RadMD will allow you to submit an authorization request for any procedure managed by Evolent.
Selecting “Physician’s office that orders procedures” will allow you to initiate authorization requests for MSK procedures.

Prospective users should go to RadMD.com

  • Click “New User”. 
  • Choose “Physician’s office that orders procedures” from the drop-down box.
  • Complete application with required information.
  • Click “Submit

When a RadMD application is successfully submitted, users receive an email with a link to create a password. Please contact the RadMD Support Team at 1-800-327-0641 if you do not receive a response within 72 hours. 

Rendering provider access allows users to view all approved authorizations for their office or facility. If an office is interested in signing up for rendering access, you will need to designate an account administrator. 

  • Prospective users should go to RadMD.com
  • Select “Facility/Office where procedures are performed” from the drop-down box.
  • Complete application with required information
  • Click “Submit”

Examples of a rendering providers that only need to view approved authorizations:

  • Hospital facilities
  • Billing departments
  • Offsite locations
Clicking the “Request Spine Surgery or Orthopedic Surgery” link will allow the user to submit a request for an MSK surgery.
Providers can check on the status of an authorization by using the “View Request Status” link on the RadMD main menu.
Clinical Information that has been received via upload or fax can be viewed by selecting the member on the View Request Status link from the main menu. On the bottom of the “Request Verification Detail” page, select the appropriate link for the upload or fax.
Links to case-specific communication to include requests for additional information and determination letters can be found via the “View Request Status” link.
The “Track an Authorization” feature allows users who did not submit the original request to view the status of an authorization, as well as upload clinical information. This option is also available as a part of your main menu options using the “Search by Tracking Number” feature. A tracking number is required with this feature.

Evolent defaults communications including final authorization determinations to paperless/electronic. Correspondence for each case is sent to the email address of the individual who submitted the authorization request. 

Users will be sent an email when determinations are made. 

  • No PHI will be contained in the email. 
  • The email will contain a link that requires the user to log into RadMD to view PHI. 

Providers who prefer paper communication will be given the option to opt out and receive communications via fax.

For RadMD assistance, please contact RadMDSupport@evolent.com or call 1-800-327-0641.

RadMD is available 24/7, except when maintenance is performed every third Thursday of the month from 9 p.m. – midnight PST.
Providers can contact:

Andrew Dietz, DPT
Senior Manager – Provider Solutions

407-967-4636
Adietz@evolent.com