CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Evolent Prior Authorization Programs for Joint/Spine Surgery and Interventional Cardiology

This document announces Neighborhood Health Plan of Rhode Island's implementation of Evolent-managed prior authorization programs for non-emergent joint surgery, spine surgery, and interventional cardiology services affecting Neighborhood Medicaid and Medicare provider networks.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEvolent prior authorization programs for Joint/Spine Surgery and Interventional Cardiology

Policy CodePolicy N/A

Change TypeNotice of implementation

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionProviders must obtain prior authorization via RadMD.com or by calling Evolent at 1-877-469-7949 before rendering non-emergent joint, spine, or interventional cardiology services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2026authorizations can be initiated

Feb 1, 2026claims require authorization

60 daysauthorization validity

Real-timestatus capability

7d / 72hturnaround times

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 Authorization Requirements

Prior authorization required (Coverage stance)

Prior authorization is required for non-emergent Joint Surgery, Spine Surgery, and Interventional Cardiology services for Neighborhood Medicaid and Medicare members as managed by Evolent.

ALL of the following

Service in scope
- Non-emergent joint surgery (including hip, knee, and shoulder surgery)
- Non-emergent spine surgery (including lumbar and cervical spine surgery)
- Non-emergent interventional cardiology services (cardiac catheterization/intervention, electrophysiology, vascular radiology/intervention, cardiac/vascular surgery)
ALL of the following
- Services rendered in outpatient or inpatient settings are subject to prior authorization
- Authorizations must be obtained prior to rendering the service; ordering or rendering providers are responsible for obtaining authorization
ALL of the following
- Authorizations can be initiated in Evolent's portal (RadMD) beginning January 1, 2026
- Claims with dates of service on or after February 1, 2026 require prior authorization
ALL of the following
- Include the authorization number/request ID on claims once a determination is made; RadMD tracking numbers are numeric and are available upon submission
- Authorizations are valid for 60 calendar days from the date of service or, if no date of service, from the request date
ALL of the following
- Failure to obtain required authorization may result in denial of payment; members must not be billed for denied services
- Prior authorization does not guarantee payment; payment remains subject to eligibility, covered benefits, provider contracts, and correct coding and billing

ALL of the following

How to request
- Submit requests via RadMD (RadMD.com)
- Call Evolent at 1-877-469-7949 to request authorization
ALL of the following
- Evolent provides real-time authorizations and real-time status of authorization requests
- Evolent offers quick turnaround, specialty-matched peer-to-peer reviews, and dedicated provider engagement representatives
ALL of the following

ALL of the following

Transition and timing
- Authorizations issued before February 1, 2026 remain effective until their end date; upon expiration, submit requests to Evolent
- For services that did not require authorization prior to January 1, 2026, an authorization will be required for service dates on and after February 1, 2026

Services in Scope and Timing

Services in scope (high-level)mixed

Services in scope include cardiac catheterization/intervention, electrophysiology, vascular radiology/intervention, cardiac/vascular surgery, lumbar/cervical spine surgery, hip/knee/shoulder surgery.

Turnaround times — Standard/Expedited

Standard turnaround timeStandard request: 7 calendar days (72 hours referenced as standard timeframe in text)

Expedited turnaround time — MedicaidExpedited request: 7 calendar days (Medicaid expedited distinction noted)

Expedited turnaround time — MedicareExpedited request: 72 calendar hours (Medicare expedited distinction noted)

What Providers Must Do

Prior Authorization

Prior Authorization Required

Providers must obtain prior authorization before rendering non-emergent Joint Surgery, Spine Surgery, or Interventional Cardiology services. Ordering or rendering providers are responsible for securing authorization prior to the service. Verify authorizations via RadMD.com or by calling Evolent at 1-877-469-7949. Failure to obtain required authorization may result in claim denial and non-payment.

Providers responsible: ordering or rendering provider
Verify authorization: RadMD.com or 1-877-469-7949

Note

Authorization Identifiers and Use

Evolent issues two identifier types: RadMD tracking numbers and alphanumeric authorization (Request ID) numbers. RadMD tracking numbers are numeric only and are available once the authorization request has been submitted; they can be used to locate a request in Evolent's system. The authorization number (Request ID) contains letters and numbers and is issued once a determination has been made; this authorization number should be included on claim submissions.

RadMD tracking number: numeric digits only; available upon submission

Key Terms

Evolent — definition and role

Organization roleEvolent is a comprehensive interventional cardiology and musculoskeletal (MSK) quality management company that administers prior authorization management for specified non-emergent services for Neighborhood Health Plan of Rhode Island.

Scope of responsibilityEvolent administers authorizations and employs licensed medical reviewers who use nationally recognized clinical guidelines to perform reviews.

Operational featuresEvolent provides access to clinical guidelines via RadMD.com and supports real-time authorization workflows and provider engagement (training and support).

RadMD tracking vs authorization/request ID

RadMD tracking number (numeric)Numeric-only identifier available immediately upon submission; can be used to locate an authorization in Evolent's system.

Authorization number / Request ID (alphanumeric)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEvolent prior authorization programs for Joint/Spine Surgery and Interventional Cardiology

Policy CodePolicy N/A

Change TypeNotice of implementation

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionProviders must obtain prior authorization via RadMD.com or by calling Evolent at 1-877-469-7949 before rendering non-emergent joint, spine, or interventional cardiology services.

SourceLink

On This Page

Clinical reviews are performed by licensed practitioners using nationally recognized clinical guidelines available at RadMD.com

Authorization/Request ID: alphanumeric; available after determination; include on claims

Denial Risk

Authorization Validity and Denial Risk

RadMD authorizations are valid for 60 calendar days from the date of service; if no date of service is provided, validity is 60 calendar days from the request date. Note that prior authorization does not guarantee payment—coverage depends on eligibility, benefits, contract terms, and correct coding. If providers fail to obtain required authorization, Neighborhood may deny payment; members must not be billed for denied services and providers may be financially responsible.

Validity: 60 calendar days from date of service (or from request date if no DOS)
Prior authorization ≠ payment guarantee
If authorization not obtained: possible denial of payment; members cannot be billed; provider financial responsibility possible

Note

Operational Support and Training

Evolent provides operational supports to aid providers: real-time authorizations and status, quick turnaround times (standard and expedited TATs apply), specialty-matched peer-to-peer reviews, and dedicated provider engagement representatives. Training and program information were provided in October 2025 and additional training requests can be directed to providertraining@evolent.com. Authorizations may be initiated in Evolent's portal beginning January 1, 2026; requests for services with dates of service on/after February 1, 2026 require authorization.

Real-time authorizations and status updates
Quick turnaround; specialty-matched peer-to-peer reviews
Dedicated provider engagement representatives and training (providertraining@evolent.com)
Authorization acceptance begins January 1, 2026; claims require authorization for DOS on/after February 1, 2026

Alphanumeric identifier issued once a determination has been made; must be included on claims and can be used to find the request in Evolent's system.

Validity and useInclude the authorization number/request ID on claims; RadMD tracking is useful for locating submissions prior to determination.