ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Delegation Of Joint_Spine Surgery And Interventional Cardiology Services To Evolent

Announces delegation of medical management for non-emergent Joint/Spine Surgery and Interventional Cardiology services to Evolent for Neighborhood Health Plan of Rhode Island Medicaid and Medicare lines; effective dates require prior authorization for specified services and age groups and describes portal access and provider responsibilities. Commercial line is not included.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDelegation Of Joint_Spine Surgery And Interventional Cardiology Services To Evolent

Policy CodePolicy N/A

Change TypeDelegation with new prior authorization requirements

Effective DateAug 21, 2025

Next Review Date

Key ActionObtain prior authorization from Evolent prior to rendering delegated Interventional Cardiology and Joint/Spine Surgery services for Medicaid and Medicare members; requests may be submitted starting 2026-01-01 for services with dates of service on or after 2026-02-01.

SourceLink

POLICY UPDATE CHANGES

Delegation of Joint/Spine Surgery and Interventional Cardiology medical management to Evolent for Medicaid and Medicare lines.

Prior authorization requirement for non-emergent Interventional Cardiology services for adults >=19 years.

2Delegated Programs

2026-02-01Prior Authorization Effective

2026-01-01

What is changing

Neighborhood Health Plan of Rhode Island is delegating medical management (prior authorization) for specified non-emergent Joint/Spine Surgery and non-emergent Interventional Cardiology services to Evolent for its Medicaid and Medicare lines of business. Neighborhood's Commercial line is not included.

Evolent will assume prior authorization responsibility for the listed non-emergent procedures; Neighborhood will continue to retain claims adjudication.

This delegation introduces a prior authorization requirement effective for dates of service on 2026-02-01, with providers able to begin submitting authorization requests on 2026-01-01 (Commercial excluded).

Key Thresholds & Dates

Delegated Programs2

Prior Authorization Effective Date2026-02-01

Authorization Submission Start Date2026-01-01

Member Age for Interventional Cardiology delegation>= 19 years

Joint/Spine Surgery prior authorization requirement

Joint/Spine Surgery Prior Authorization Requirement

Effective for dates of service on or after February 1, 2026, prior authorization will be required for the following non-emergent Joint/Spine Surgeries. Providers may begin submitting requests starting January 1, 2026.

ALL of the following

Non-emergent joint/spine procedure mapping: Service is a non-emergent Joint/Spine Surgery listed in Neighborhood/Evolent procedure mapping (includes but not limited to Revision/Conversion Hip Arthroplasty, Total Hip, Hip Surgery - Other, Knee Surgery procedures including Total Knee Arthroplasty (TKA), Partial-Unicompartmental Knee Arthroplasty (UKA), Knee Manipulation under Anesthesia, Shoulder Surgery procedures including Revision Shoulder Arthroplasty, Total/Reverse Shoulder Arthroplasty or Resurfacing, Shoulder Labral Repair, Partial Shoulder, Rotator Cuff Repair, and specified spinal surgery procedures such as Cervical and Lumbar decompression/fusion/artificial disc and Sacroiliac Joint Fusion).
Document includes mapping lines grouping many procedure categories; exact CPT/Coding list to be published separately via Evolent portal.
Date of service: Procedure date of service on or after 2026-02-01

Interventional Cardiology prior authorization requirement

Interventional Cardiology Prior Authorization Requirement

Effective for dates of service on or after February 1, 2026, prior authorization will be required for non-emergent Interventional Cardiology services for adults 19 years of age or older. Providers may begin submitting requests starting January 1, 2026.

ALL of the following

Non-emergent interventional cardiology: Service is a non-emergent Interventional Cardiology procedure included on Evolent authorization list (complete CPT list published separately)
Emergent Interventional Cardiology services are excluded from prior authorization requirement.
Member age is >= 19 years>= 19 years
Interventional Cardiology services delegated to Evolent apply only to members 19 years of age or older.

Prior authorization exceptions / not required

Prior Authorization Exceptions / Not Required

ANY of the following

Emergent services excluded: Emergent Interventional Cardiology services
Excluded from requiring prior authorization.
Care settings excluded: Emergency Room, Urgent Care, and Newborn Inpatient services
Do not require prior authorization from Evolent for these services.

Coding (to be published)

CPT/Procedure codes (to be published)CPT

No codes listed

Action required for providers

Prior Authorization

Obtain prior authorization from Evolent

Ordering or rendering providers are responsible for obtaining prior authorization from Evolent prior to rendering delegated Interventional Cardiology and Joint/Spine Surgery services for Neighborhood Medicaid and Medicare members. Requests may be submitted beginning 2026-01-01 for services with dates of service on or after 2026-02-01.

Authorization submission start date: 2026-01-01
Applies to services with dates of service on or after 2026-02-01

Documentation Required

Confirm authorization status

Rendering providers should confirm that authorization has been obtained before rendering services by visiting RadMD.com or calling Evolent at 1-877-469-7949. Claims may be denied if authorization is not secured.

Definitions

Non-emergent: Services not meeting emergency criteria; emergent Interventional Cardiology services remain excluded from prior authorization.

Note: Emergency Room, Urgent Care, and Newborn Inpatient services do not require prior authorization from Evolent.

Interventional Cardiology delegation for prior authorization applies to members aged >= 19 years (non-emergent only) and is effective for dates of service on or after 2026-02-01 (requests accepted beginning 2026-01-01).

Frequently asked questions

Question	Answer
Which lines of business are included in the delegation?
Medicaid and Medicare lines are included; Neighborhood's Commercial line is not included.
When may providers begin submitting prior authorization requests to Evolent?
Providers may begin submitting requests on January 1, 2026 for services with dates of service on or after February 1, 2026.

Policy update changes

2026-02-01policy_effectiveLatest

Effective for dates of service on or after February 1, 2026, prior authorization is required for non-emergent Joint/Spine Surgery for Neighborhood Medicaid and Medicare members; providers may begin submitting requests on January 1, 2026. Neighborhood's Commercial line is excluded. Evolent will manage medical management while Neighborhood retains claims adjudication.

2026-02-01policy_effectiveLatest

Effective for dates of service on or after February 1, 2026, prior authorization is required for non-emergent Interventional Cardiology services for adults aged 19 years and older for Neighborhood Medicaid and Medicare members; providers may begin submitting requests on January 1, 2026. Neighborhood's Commercial line is excluded.