CurrentFidelis CarePolicy N/A

Utilization Review Matrix — Advanced Imaging and Cardiac Services

Lists CPT and related codes managed by Evolent on behalf of Fidelis Care, defines allowable billed groupings when a procedure is authorized, and explains settings and conditions where Evolent management does not apply; applies to providers submitting claims to Fidelis Care in North Carolina.

Policy Summary

PayerFidelis Care

PolicyUtilization Review Matrix — Advanced Imaging and Cardiac Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionEvolent manages prior authorization and utilization review for the listed advanced imaging and cardiac CPT codes on behalf of Fidelis Care; prior authorization is not required for Exchange plans beginning February 23, 2024.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+CPT and related codes listed in the matrix

MultipleAllowable billed groupings provided

ER/Obs/FacilityExcluded settings

Waived Feb 23, 2024Exchange plans prior auth waived

Coverage and Adjudication Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and adjudication criteria

Covered/adjudicated when ALL of the following rules are met:

ALL of the following

Member is eligible at the time of service, appropriate re-bundling rules are applied, the claim includes an appropriate diagnosis code for the CPT code, and the service is performed within the validity period.
If a procedure family is listed, any ONE of the listed Allowable Billed Groupings may be submitted to represent the authorized service.
ALL of the following
- If a family of CPT codes is NOT listed in the matrix, an exact match is required between the authorized CPT code and the billed CPT code.
- If the exact match does not occur, the charge should be adjudicated accordingly.
Settings excluded from Evolent management
- Services rendered in an Emergency Room setting are not managed by Evolent.
- Services rendered in Observation Status are not managed by Evolent.
- Services rendered in a Surgery Center are not managed by Evolent.
- Services rendered in an Urgent Care Center are not managed by Evolent.
- Services rendered in a Hospital Inpatient setting are not managed by Evolent.
Payment for add-on (+) codes may depend on the appropriateness of their application relative to the approved primary code.
Authorization exception
- Prior authorization is not required for members with Exchange plans beginning February 23, 2024.

CPT Codes and Allowable Billed Groupings

Selected example CPT codes and allowable billed groupingsCPT

70450	CT Head/Brain; allowable billed groupings include 70450,70460,70470,+0722T
70551	MRI Brain; allowable billed groupings include 70551,70552,70553,+0698T
75574	CTA coronary arteries (CCTA); allowable billed grouping = 75574
93307	Transthoracic Echocardiography (TTE); allowable billed groupings include 93303,93304,93306,93307,93308,+93320,+93321,+93325,+93356
78429	Heart PET Scan with CT for Attenuation; allowable billed groupings include 78459,78491,78492,+78434,78429,78430,78431,78432,78433

Exact match requirement when family not listed

RequirementIf a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code.

Adjudication actionIf the exact match does not occur, the charge should be adjudicated accordingly.

ScopeApplies to CPT families not listed in the Fidelis/Evolent matrix for advanced imaging and cardiac services.

Prior Authorization and Provider Responsibilities

Prior Authorization

Evolent manages prior authorization for listed codes; exceptions and Exchange plan waiver

Evolent (formerly National Imaging Associates) manages prior authorization and utilization review for the advanced imaging and cardiac CPT codes listed in this matrix on behalf of Fidelis Care. Management does not apply to services rendered in Emergency Room, Observation Status, Surgery Center, Urgent Care Center, or Hospital Inpatient settings. Prior authorization is not required for members with Exchange plans beginning February 23, 2024.

Evolent manages prior authorization and utilization review for the listed CPT codes on behalf of Fidelis Care.
Services in ER, Observation, Surgery Center, Urgent Care, or Hospital Inpatient settings are not managed by Evolent.
Prior authorization waived for members with Exchange plans beginning 02/23/2024.

Key Terms and Managed Settings

Allowable Billed Groupings — definition

DefinitionAllowable Billed Groupings are the list of procedure codes that may be submitted on a claim to represent an authorized service when a given procedure family is authorized.

ConditionsSubmission assumes member eligibility at time of service, appropriate re-bundling rules, appropriate diagnosis code, and service performed within the validity period.

PurposeHelps resolve claims adjudication and claims questions related to services authorized by Evolent on behalf of Fidelis Care.

Managed settings exception

ExceptionServices rendered in Emergency Room, Observation Status, Surgery Center, Urgent Care Center, or Hospital Inpatient setting are not managed by Evolent.

Effect on matrixThese settings are out of scope for the Fidelis/Evolent utilization review matrix; Evolent prior authorization/management does not apply.

Provider implicationDo not rely on Evolent authorization requirements for services performed in these settings when adjudicating claims.