Evolent (formerly NIA)

Effective January 1, 2024, National Imaging Associates, Inc. (NIA) became Evolent Specialty Services, Inc. (Evolent). They are in the process of updating their provider resources to reflect this branding.

Advanced Diagnostic Imaging

Iowa Total Care has contracted with 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.

Iowa Total Care oversees the Evolent program and is responsible for claims adjudication. Evolent manages non-emergent outpatient imaging/radiology services through contractual relationships with freestanding facilities.

Prior authorization is required for the following outpatient radiology procedures:

CT/CTA/CCTA
MRI/MRA
PET scan

Cardiac Solutions

Iowa Total Care, in collaboration with Evolent, will launch a cardiac imaging program to promote healthcare quality for patients with possible cardiac disease.

Under this program, prior authorization will be required for certain cardiac studies to determine if the cardiac test or procedure is the most appropriate next step in a patient’s diagnosis or treatment—and to recommend an alternate approach when indicated. By supporting the most efficient diagnosis and management of cardiac disease, Evolent addresses unnecessary procedures and promotes the least invasive, most medically appropriate approach.

Prior authorization is required for the following cardiac procedures through Evolent:

Myocardial perfusion imaging (MPI)
MUGA scan
Echocardiography
Stress Eehocardiography

Interventional Cardiology Solutions Program

Iowa Total Care has partnered with Evolent (formerly New Century Health), to implement a new prior authorization program. Evolent’s Interventional Cardiology Solutions program helps providers effectively deliver quality patient care.

Effective January 1, 2025, interventional cardiology procedures and services will require prior authorization through Evolent prior to being rendered in a provider office, outpatient hospital, ambulatory or inpatient setting (planned professional services only). This prior authorization management program will apply to Iowa Total Care Medicaid members 18 years of age and older.

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

Cardiac catheterization and intervention
Electrophysiology
Vascular radiology and intervention
Cardiac surgery
Vascular surgery

Submit prior authorization requests for interventional cardiology services to Evolent:

Evolent (CarePro) provider portal at my.newcenturyhealth.com.
Via telephone at 1-888-999-7713, cardiology (option 1). Staff is available Monday – Saturday, 7 a.m. to 7 p.m. CT.

Additional Resources:

Interventional Pain Management (IPM)

As of June 1, 2023, the prior authorization program with Evolent was expanded to include the following non-emergent outpatient Medical Specialty Solution procedures:

Spinal Epidural Injections
Paravertebral Facet Joint Injections or Blocks
Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)
Sacroiliac Joint Injections
Spinal Cord Stimulators

Providers may contact Evolent to seek prior authorization for procedures and Evolent will manage these procedures through Iowa Total Care’s contractual relationships.

Additional Resources:

Physical Medicine (Therapy) Program

As of April 1, 2022, outpatient physical, occupational and speech therapy requests will be reviewed by Evolent’s peer consultants to determine whether the services meet policy criteria for medically necessary and appropriate care. The medical necessity determinations are based on a review of objective, contemporaneous and clearly documented clinical records that may be requested to help support the appropriateness of care. Clinical review helps determine whether such services are both medically necessary and eligible for coverage.

All members are eligible for four (4) visits per rolling benefit year, per discipline without authorization. All other visits and CPT codes following the four (4) visits will require authorization through Evolent prior to services being rendered and billed. Prior authorization can be obtained through the Evolent website or by contacting Evolent at 1-866-493-9441.

Additional Resources:

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.

Evolent Education Material

Providers redering 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.