Evolent Specialty Services
Health Net has contracted with Evolent Specialty Services Inc. (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.
Health Net oversees the Evolent program and is responsible for claims adjudication.
For Medi-Cal, and Commercial HMO/PPO/POS including Ambetter HMO/PPO, prior authorization is required for the following outpatient radiology procedures:
- Advanced imaging:
- Computed tomography (CT)/Computed tomography angiography (CTA)
- Magnetic resonance imaging (MRI)/Magnetic resonance angiography (MRA)
- Positron emission tomography (PET) scan
- Cardiac imaging:
- Coronary computed tomography angiography (CCTA)
- Myocardial perfusion imaging (MPI)
- Multigated acquisition (MUGA)
Emergency room, observation, and inpatient imaging procedures do not require authorization.
Prior Authorization Requests
Prior authorization requests must be submitted to Evolent Specialty Services Inc. (Evolent) online or by telephone as follows. Evolent does not accept fax submissions.
- Online - Post-log in at www.RadMD.com, 24 hours a day, seven days a week, except when maintenance is performed once every other week after business hours.
- Telephone, available Monday through Friday, from 8:00 a.m. to 8:00 p.m.
Expedited authorization requests may only be submitted by telephone.
To expedite the request process, providers must have the following information ready before logging in to the Evolent website or calling (* denotes required information):
- Name and office telephone number of ordering provider.*
- Member name and identification (ID) number.*
- Requested examination.*
- Name of provider office or facility where the service will be performed.*
- Anticipated date of service (if known).
- Details justifying the examination.*
- Symptoms and their duration.
- Physical exam findings, including findings applicable to the requested services, conservative treatment the member has already completed (such as physical therapy, chiropractic or osteopathic manipulation, hot pads, massage, ice packs, and medication).
- Results and/or reports of preliminary procedures already completed (such as X-rays, CTs, lab work, ultrasound, scoped procedures, referrals to specialist, and specialist evaluation).
- Reason the study is being requested (such as further evaluation, rule out a disorder).
The following information may also be requested:
- Clinical notes
- Reports of previous procedures
- Specialist reports/evaluation
Best practice
Submit a Conservative Treatment Form with the Prior Authorization Request and relevant clinical records before ordering the imaging study. Download the form on the Evolent website under Conservative Treatment Forms. The Conservative Treatment Form details all of the documentation regarding conservative care that is required to meet medical necessity criteria for consideration in an authorization decision. Please note, not all services require a conservative treatment form to be submitted. Additionally, a conservative treatment form does not need to be submitted if all elements are documented in the clinical records submitted.
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. A separate prior authorization number is required for each procedure ordered.
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 in those instances is required through the health plan. To obtain authorization through Evolent or for more information, visit Evolent website.