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 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

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Clinical & Payment Policies

Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Ambetter from Meridian Clinical Policy Manual apply to Ambetter from Meridian members. Policies in the Ambetter from Meridian Clinical Policy Manual may have either a Ambetter from Meridian or a “Centene” heading. Ambetter from Meridian utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from Meridian clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Ambetter from Meridian. In addition, Ambetter from Meridian may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Ambetter from Meridian.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Ambetter from Meridian Payment Policy Manual apply with respect to Ambetter from Meridian members. Policies in the Ambetter from Meridian Payment Policy Manual may have either a Ambetter from Meridian or a “Centene” heading.  In addition, Ambetter from Meridian may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Ambetter from Meridian.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Change Healthcare Connection FAQ
This document contains frequently asked questions regarding Availity’s decision to connect to Change Healthcare’s rebuilt clearinghouse CHC Green System, also known as the Relay Clearinghouse. For clarity, the clearinghouse will be called the CHC Green System in this document.

This FAQ will be added to our the Availity Lifeline: Essentials Pro Customer Resource Center microsite and other areas and updated as more information becomes available.

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