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.
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.
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
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.
No, for Medicare Advantage plans.
Evolent’s medical necessity review and determination is for the authorization of the surgeon’s professional services and type of surgery being performed.
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.
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.
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.
Who should a provider contact if they want to appeal a prior authorization or claims payment denial?
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.
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.
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.
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
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.
RadMD is available 24/7, except when maintenance is performed every third Thursday of the month from 9 p.m. – midnight PST.
Andrew Dietz, DPT
Senior Manager – Provider Solutions
407-967-4636
Adietz@evolent.com