Evolent Health
Musculoskeletal Surgical Procedures Benefit Management
Health Net Health Plan of Oregon, Inc. has contracted with Evolent Health for musculoskeletal surgical procedures benefit management.
The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for our members.
Prior Authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to Evolent and will be required for the following surgical procedures in both inpatient and outpatient settings.
Please use the Pre-Auth Check Tool to confirm prior authorization requirements or contact Evolent for additional information.
Orthopedic Surgical Procedures
Including all associated partial, total, and revision surgeries
- Knee arthroplasty
- Unicompartmental/bicompartmenral knee replacement
- Hip arthroplasty
- Shoulder arthroplasty
- Elbow arthrosplasty
- Ankle arthroplasty
- Wrist arthroplasty
- Acromioplasty and rotator cuff repair
- Anterior cruciate ligament repair
- Knee arthroscopy
- Hip resurfacinjg
- Meniscal repair
- Hip arthroscopy
- Femoroacetabular arthroscopy
- Ankle fusion
- Shoulder fusion
- Wrist fusion
- Osteochondral defect repair
Spinal Surgical Procedures
Including all associated partial, total, and revision surgeries
- Spinal fusion surgeries
- cervical
- lumbar
- thoracic
- sacral
- scoliosis
- cervical
- Disc replacement
- Laminectomy/discectomy
- Kyphoplasty/vertebroplasty
- Sacroiliac joint fusion
- Implantable pain pumps
- Spinal cord neurostimulator
- Spinal decompression
Key Provisions:
- Emergency-related procedures do not require authorization
- It is the responsibility of the ordering physician to obtain authorization
- 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 claims.
Radiology Benefit Management
Health Net has contracted with Evolent Health 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. Evolent manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.
Prior authorization is required for the following outpatient radiology procedures:
- CT/CTA/CCTA
- MRI/MRA
- PET Scan
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.
Go to the Evolent website for more information.
Radiation Oncology Benefit Management
Health Net has contracted with Evolent Health, an oncology benefit management company, for radiation oncology benefit management.
The program includes management of non-emergent outpatient and surgical radiation oncology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and utilization of these services.
Health Net oversees the Evolent program and is responsible for claims adjudication. Evolent manages non-emergent outpatient and surgical radiation oncology services through contractual relationships with free-standing facilities.
Prior authorization is required for the following procedures:
- Gynecology Oncology
- Hematology Oncology
- Medical Oncology
- Neuro Oncology
- Pediatric Oncology
- Radiation Oncology
- Surgical Oncology
- Urology
Key Provision:
Providers rendering these services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.
Go to the Evolent website for more information.