Frequently Asked Questions Oncology Quality Management Program, Radiation Oncology: Ambetter of Illinois, Effective June 1, 2026

Fecha: 27/02/26

• Who is Evolent?
  • Evolent (formerly New Century Health) is a comprehensive Oncology Quality Management Company whose goal is to apply evidence-based treatment to the delivery of radiation oncology care.

• What is the Oncology Quality Management Program?
  • The Oncology Quality Management Program provides prior authorization management for 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 members age 19 and older.
• When will the program begin?
  • The program will begin on June 1, 2026.

• How can a physician’s office request training for this program?
  • A provider solutions specialist will contact you to schedule an introductory meeting and training. For questions before the introductory meeting, please contact Evolent at 888-999-7713, option 6, or email providertraining@evolent.com.

• What are some key features of the program?
  • Evolent offers:
    • 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

• How do I contact Evolent authorization support?
  • Call 888-999-7713, (radiation oncology - option 3). Staff are available Monday-Friday, 7 a.m. to 7 p.m. CST.

• What is the transition of care process?
  • Ambetter of Illinois approvals issued before June 1, 2026, are effective until the authorization end date. Beginning June 1, 2026, please submit prior authorization requests to Evolent.

• Who is responsible for obtaining prior authorization?
  • The physician organization ordering radiation oncology services must request prior authorization through Evolent.

• How do I obtain prior authorization?
  • Submit requests to Evolent,
    • Online com/provider-portal, select CarePro
    • Via telephone at 888-999-7713, (radiation oncology, option 3)
      
      
• What is the turn-around time (TAT) for processing prior authorization requests?

• What services require prior authorization?
  • The Oncology Quality Management Program, administered by Evolent, requires prior authorization management for radiation oncology services for members with a diagnosis code included in the following ranges:
    
    Cancer Diagnoses = C00 - D09, D37 - D44, E34.0 
    
    Hematology Diagnosis = D45-D49, D59.10-D59.19, D61.81, D61.82, D63.0, D63.8, D64.2-D64.3, D64.81, D64.89, D64.9, D68.59, D69.3, D69.41, D69.59, D69.6, D69.8, D69.9, D70.1-D70.9, D72.8, D72.9, D73.81, D73.9, D75.1, D75.81, D75.82 
    
    Evolent authorization required for: Brachytherapy, Conformal, Conventional, IMRT, IGRT, Proton and Neutron Beam Therapy and Stereotactic Radiosurgery.

• Which specialties are included in the Oncology Quality Management Program?
  • Ordering provider oncology specialties will submit their prior authorizations through Evolent: Gynecologic Oncology, Hematology, Medical Oncology, Radiation Oncology, Surgical Oncology and Urology.

• Who reviews radiation oncology requests?
  • Evolent medical reviewers are licensed radiation oncologists using nationally recognized clinical guidelines when performing reviews. Clinical guidelines are available at com/provider-portal or by contacting Evolent at 1.888.999.7713, option 3 for radiation oncology.

• 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 six digits (e.g., AR100000) and be valid for the duration indicated on the Service Request Authorization (SRA).

• Which place(s) of service are included in this program?
  • Radiation oncology services rendered in a physician’s office, outpatient hospital, or ambulatory setting.

• Does prior authorization guarantee payment?
  • 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 details, please refer to the Ambetter provider manual.

• Who is responsible for responding to grievances and appeals?
  • Ambetter of Illinois 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 of Illinois may deny payment for the relevant services.