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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 Commercial HMO/PPO/POS and Ambetter HMO/PPO, prior authorization is required for the following outpatient radiology procedures:

  • CT/CTA/CCTA
  • MPI
  • MRI/MRA
  • MUGA scan
  • PET scan

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.

Last Updated: 05/23/2024