January 26, 2024
Dear Provider,
All of us at Wellcare are committed to continuous improvement of quality services for our members. With that in mind, Wellcare has entered into an expanded partnership with Evolent, formerly National Imaging Associates, Inc. (NIA), to implement a new Musculoskeletal (MSK) Management program. This will impact our Wellcare (Medicare Advantage Plans).
The MSK program currently requires prior authorization for non-emergent outpatient, interventional spine pain management services (IPM), and will be expanded to include spinal cord stimulators, and inpatient and outpatient hip, knee, shoulder, lumbar, and cervical spine surgeries for our members. The decision to implement this latest program is consistent with industry-wide efforts to ensure clinically-appropriate quality of care and to manage the increasing utilization of these services.
In consideration of this agreement, the current MSK program with TurningPoint Healthcare will terminate as of March 31, 2024.
Under terms of the agreement between our Michigan plans and Evolent:
- We will oversee the MSK program and continue to be responsible for claims adjudication and medical policies.
- Evolent will manage IPM services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with us.
Planned for an April 1, 2024 implementation, this correspondence serves as notice under your Participating Provider Agreement of changes to the program.
Providers may begin contacting Evolent on April 1, 2024, to seek prior authorization for procedures scheduled on or after April 1, 2024..
KEY PROVISIONS:
- It is the responsibility of the ordering physician to obtain prior authorization for all IPM procedures and MSK surgeries managed by Evolent.
- Evolent does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency department or for MSK surgery procedures outside of those procedures listed above.
- The ordering physician must obtain prior authorization with Evolent prior to performing the surgery/procedure.
- Facility admissions do not require a separate prior authorization. However, the facility should ensure that an Evolent prior authorization has been obtained prior to scheduling the surgery/procedure.
MSK surgeries other than those outlined above will continue to follow prior authorization requirements for hospital admissions and elective surgeries as outlined for each line of business.
Please visit RadMD.com for a complete list of CPT codes included in this program.
We appreciate your support and look forward to your assistance in assuring that your patients receive MSK services delivered in a quality, clinically-appropriate fashion.
We will provide additional information as we get closer to the implementation date. Should you have any questions, please contact our Provider Services Department at 1-855-538-0454.
Sincerely,
Wellcare
