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Evolent to Handle Ambetter Health Cardiovascular Auths

Date: 02/24/25

Ambetter Health has partnered with Evolent (formerly New Century Health), a comprehensive cardiovascular quality management company, to implement a new prior authorization (PA) program. The Evolent Cardiology Solution Program is designed to help providers easily and effectively deliver quality patient care.

Starting April 1, 2025, invasive cardiovascular procedures and services rendered in a physician’s office, outpatient hospital, and ambulatory or inpatient setting will require prior authorization from Evolent. This will apply to all Ambetter Health members ages 19 years and older. Ambetter Health will directly manage cardiology services for members ages 18 and younger.

TurningPoint will no longer provide cardiology services for Ambetter Health members effective April 1, 2025. TurningPoint authorizations issued before April 1, 2025, will remain in effect until the authorization end date.

Under the new PA program, providers will use these Evolent Cardiology Solution Program Codes for Ambetter Health.

The Evolent Cardiology Solution Program will apply to all specialties for the following invasive cardiovascular services only:

  • Cardiac Catheterization and Intervention
  • Cardiac Surgery
  • Electrophysiology
  • Vascular Radiology and Intervention
  • Vascular Surgery

Beginning April 1, 2025, providers must submit prior authorization requests for invasive cardiology services to Evolent for Ambetter Health members ages 19 years and older:

Evolent uses clinical criteria based on nationally recognized guidelines to promote evidence-based practices. The Evolent CarePro Provider Portal will allow providers to:

  • Obtain real-time approvals when selecting evidence-based treatment care pathways
  • Determine the clinical documentation required for medical necessity review
  • View all submitted requests
  • Request to speak with clinicians to discuss treatment options

Evolent will contact providers who frequently request cardiovascular services and are new to this process to schedule an introductory meeting and training.

Evolent is responsible for authorization reviews. Providers not contracted with Ambetter Health wishing to provide cardiac services can contact 1-877-687-1169. Ambetter Health will reach out to you regarding participation after you provide the requested information.

Ambetter Health will directly manage cardiology services for members ages 18 years and younger, where authorizations can be requested by visiting Secure Provider Portal.

Evolent Questions?

If you have questions for Evolent, please email providertraining@evolent.com or call 1-888-999-7713 and select Option 6.

Ambetter Health Questions?

Ambetter Health has a wealth of resources available to help answer your questions and address your concerns:

Evolent Cardiology Solution Program Frequently Asked Questions (FAQ)

Who is Evolent?

Evolent (formerly New Century Health) is a comprehensive cardiology quality management company whose goal is to apply evidence-based treatment to the delivery of cardiology care.

What is the Evolent Cardiology Solution Program?

The Evolent Cardiology Solution Program provides prior authorization management for invasive cardiovascular services rendered in a physician’s office, outpatient hospital, and ambulatory or inpatient setting (for planned professional services only). 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 Health members ages 19 years and older.

Who will manage prior auths for younger members?  

Ambetter Health will directly manage cardiology services for members ages 18 years and younger.

When does the program start?

The Evolent Cardiology Solution Program for Ambetter Health will start April 1, 2025.

How can providers request training for this program?

An Evolent provider solution manager will contact you to schedule an introductory meeting and training. If you have any questions prior to the introductory meeting, please contact Evolent by emailing providertraining@evolent.com or call 1-888-999-7713 and select option 6.

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 cardiologists
  • Support staff with dedicated provider solutions representatives available to assist

How can I contact Evolent authorization support?

Call 1-888-999-7713 and select option 1. Evolent’s staff is available Monday through Saturday, 8 a.m. to 8 p.m. Eastern.

What is the transition of care process?

TurningPoint approvals issued before April 1, 2025, are effective until the authorization end date. Starting April 1, 2025, please submit prior authorization requests to Evolent.

Who is responsible for obtaining prior authorization?

The physician organization ordering cardiology services must request prior authorization through Evolent.

How do I obtain prior authorization for Ambetter Health members?

Here’s how to submit requests to Evolent:

What is the turn-around time (TAT) for processing prior authorization requests?

Medical Services

  • Standard: Within 15 calendar days
  • Expedited: Within 3 calendar days

What services / specialists are included in the program?

The program will apply to all specialties for the following invasive cardiovascular services only:

  • Cardiac Catheterization and Intervention
  • Cardiac Surgery
  • Electrophysiology
  • Vascular Radiology and Intervention
  • Vascular Surgery

Who reviews cardiovascular requests?

Evolent medical reviewers are licensed cardiologists using nationally recognized clinical guidelines when performing reviews. Clinical guidelines are available via the Evolent CarePro Provider Portal or by calling Evolent at 1-888-999-7713 and select option 1.

What happens if the authorization request does not meet guidelines?

If the request does not meet evidence-based treatment guidelines, Evolent may request additional information or initiate a physician discussion with the requesting provider.

What will the Evolent authorization number look like, and how long is it valid?

The Evolent authorization will start with “AR” followed by at least four digits (example: AR1000). It will be valid for the 60-day duration indicated on the Service Request Authorization (SRA).

Which place(s) of service are included in this program?

Cardiovascular services rendered in a physician’s office, outpatient hospital, ambulatory, or inpatient setting (for planned professional services only).

Does prior authorization guarantee payment?

No. Prior authorization does not guarantee payment for services. Payment of claims is dependent on eligibility, covered benefits, provider contracts, and correct coding and billing practices. For specific details, please refer to your Ambetter Health Provider Manual.

Who is responsible for responding to grievances and appeals?

Ambetter Health will maintain the grievance and appeal processes.

What will happen if the physician does not request and obtain an authorization?

If authorization is not obtained, Ambetter Health may deny payment for the relevant services.

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