Cardiology Management Program

Date: 08/06/24

Magnolia Health has partnered with Evolent (formerly New Century Health) to implement a new prior authorization program. Evolent is a comprehensive Cardiology Quality Management Company. This program is intended to help providers easily and effectively deliver quality patient care.

Effective October 1, 2024, invasive cardiology procedures and services will require prior authorization through Evolent rendered in a physician’s office, outpatient hospital, ambulatory, or inpatient setting (planned professional services only) will require prior authorization through Evolent. 

Ambetter from Magnolia Health authorizations issued before October 1, 2024, will be effective until the authorization end date. This prior authorization management program will apply to your Ambetter from Magnolia Health (Exchange) members 19 years and older for adults.

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

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

Prior authorization requests for invasive cardiology services can be submitted to Evolent:

• Online my.newcenturyhealth.com.
• Via telephone at 1.888.999.7713, cardiology (option 1). Staff is available Monday-Saturday from 7:00 a.m. to 7:00 p.m. CST. 

Evolent uses clinical criteria based on nationally recognized guidelines to promote evidence-based practices. When using Evolent’s CarePro provider portal, you will be able 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.

Ambetter from Magnolia Health are proud to be your healthcare partner. If you frequently request cardiology services and are new to this process, Evolent representatives will contact you soon to schedule an introductory meeting and in-service training.

If you have questions about the Evolent cardiology services program, please email providertraining@evolent.com or call 1.888.999.7713, (option 6).

Frequently Asked Questions: Cardiology Management Program

• 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 Cardiology Quality Management Program? 
  • The Cardiology Quality Management Program provides prior authorization management for invasive cardiology services rendered in a physician’s office, outpatient hospital, and ambulatory or inpatient setting (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 from Magnolia Health members aged 19 years and older for adults.
• When will the program begin?
  • The program will begin October 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 training. If you have any questions prior to the introductory meeting, please contact Evolent at 1.888.999.7713, option 6 or email providertraining@evolent.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 cardiologists
    • Support staff with dedicated provider solutions representatives available to assist
• How do I contact Evolent authorization support?
  • Call 1.888.999.7713 (option 1). Staff is available Monday-Friday 7:00 a.m. to 7:00 p.m. CST. 
• What is the transition of care process?
  • Ambetter from Magnolia Health approvals issued before October 1, 2024, are effective until the authorization end date. Starting October 1, 2024, 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?
  • By submitting requests to Evolent:
    • Online my.newcenturyhealth.com.
    • Via telephone at 1.888.999.7713 (option 1) 
• What is the turn-around time (TAT) for processing prior authorization requests?

• 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
    • Electrophysiology
    • Vascular Radiology and Intervention
    • Cardiac Surgery
    • Vascular Surgery
• Who reviews cardiology requests?
  • Evolent medical reviewers are licensed cardiologists using nationally recognized clinical guidelines when performing reviews. Clinical guidelines are available at my.newcenturyhealth.com or by contacting Evolent at 1.888.999.7713, 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 (e.g., AR1000) and be valid for the 60-day duration indicated on the Service Request Authorization (SRA).
• Which place(s) of service are included in this program?
  • Cardiology services rendered in a physician’s office, outpatient hospital, ambulatory, or inpatient setting (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 Provider Manual.
• Who is responsible for responding to grievances and appeals?
  • Ambetter from Magnolia 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 from Magnolia Health may deny payment for the relevant services. Members may not be held responsible or billed for denied charges/services. Providers may only be able to collect the applicable cost share amount directly from the member.