Delegation of Joint/Spine Surgery and Interventional Cardiology Services to Evolent
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Neighborhood Health Plan of Rhode Island delegates medical management (prior authorization) for specified non-emergent joint/spine surgeries and interventional cardiology services for Medicaid and Medicare members to Evolent; Commercial line is not included.
Evolent will manage prior authorization for Joint/Spine Surgery and Interventional Cardiology services for Neighborhood Medicaid and Medicare lines of business.
Commercial line of business is excluded from the delegation.
Emergent Interventional Cardiology services are excluded from prior authorization.
Coverage Criteria for Delegated Services
Authorization criteria for delegated services
Covered when ALL of the following are met:
Delegation authorization requirements
- Service type: Service is a non-emergent Joint/Spine surgery or a non-emergent Interventional Cardiology service.
- Member line of business: Member is covered under Neighborhood Medicaid or Medicare (Commercial line of business is excluded from this delegation).
- Date of service is on or after Feb 1, 2026. (Providers may begin submitting authorization requests starting Jan 1, 2026.)
- Age threshold for interventional cardiology: For Interventional Cardiology services, member age is >= 19 years.
- Authorization request process: Authorization is requested via Evolent processes (RadMD portal or by calling Evolent).
Emergent Interventional Cardiology services are excluded from authorization.
This delegation applies to Neighborhood Health Plan of Rhode Island’s Medicaid and Medicare lines of business only; the Commercial line is explicitly excluded from this delegation. The delegation covers prior authorization management for specified non-emergent Joint/Spine surgery and Interventional Cardiology services, while Neighborhood will continue to manage claims adjudication. Emergent services are not included in the prior authorization requirement: specifically, emergent Interventional Cardiology services, as well as services rendered in the Emergency Room, Urgent Care, and Newborn Inpatient settings, do not require authorization from Evolent for these services.
Ordering and rendering providers are responsible for obtaining prior authorization for delegated Joint/Spine Surgery and Interventional Cardiology services before performing the service. If authorization is not obtained prior to rendering the service, claims may be denied.
Services and Coding
| see document | Complete list of CPT codes and service descriptions requiring authorization is listed in the referenced complete list (document indicates a complete list exists). |
| Revision/ Conversion Hip | Revision/ Conversion Hip (includes Femoroacetabular Impingement (FAI) Hip Surgery; Total Hip Arthroplasty / Resurfacing; Hip Surgery - Other). |
| Knee Surgery Procedures | Knee surgery procedures including Revision Knee Arthroplasty; Total Knee Arthroplasty (TKA); Partial-Unicompartmental Knee Arthroplasty (UKA); Knee Manipulation under Anesthesia (MUA); Knee Meniscectomy/Meniscal; Knee Ligament; Knee Surgery Other. |
| Shoulder Surgery Procedures | Shoulder procedures including Revision Shoulder Arthroplasty; Frozen Shoulder Repair/Adhesive Capsulitis; Total/Reverse Shoulder Arthroplasty or Resurfacing; Shoulder Labral Repair; Partial Shoulder; Shoulder Rotator Cuff Repair; Shoulder Surgery Other. |
| Spinal Surgery Procedures | Cervical and lumbar spinal procedures including Cervical Anterior Decompression (without fusion); Cervical ACDF (single and multiple levels); Cervical Posterior Decompression (with and without fusion); Cervical Artificial Disc (single and two levels); Lumbar Microdiscectomy; Lumbar Decompression; Lumbar Fusion (single and multiple levels); Lumbar Artificial Disc (single and multiple levels); Sacroiliac Joint Fusion. |
Provider Actions and Authorization Process
Prior Authorization Required for Joint/Spine Surgery
Effective for dates of service on or after February 1, 2026, prior authorization is required for non-emergent Joint/Spine Surgery services. Providers may begin submitting authorization requests starting January 1, 2026.
- Effective DOS >= 2026-02-01
- Requests accepted beginning 2026-01-01
Provider Responsibilities
Providers are responsible for obtaining all required authorizations prior to rendering or ordering Joint/Spine Surgery and Interventional Cardiology services. This includes confirming authorization status for delegated services managed by Evolent.
- Obtain authorization before scheduling/providing service
- Confirm authorization applies to delegated Evolent-managed services
How to Obtain Authorization
Authorization requests must be submitted via Evolent's RadMD portal or by phone. Providers can request portal access at RadMD.com by completing the registration process. While portal access can be requested at any time, authorization requests may not be submitted until January 1, 2026. Neighborhood strongly encourages providers to register and become familiar with the portal prior to that date.
- Portal access: RadMD.com (complete registration)
- Phone: 1-877-469-7949
- Authorization submission allowed beginning 2026-01-01
Claims Denial Risk if Authorization Not Obtained
Claims may be denied if required authorization is not secured prior to the service for delegated Joint/Spine Surgery and Interventional Cardiology services. Note exceptions: emergent Interventional Cardiology services, Emergency Room, Urgent Care, and Newborn Inpatient services do not require authorization from Evolent.
- Claims risk of denial when authorization not obtained
- Emergent Interventional Cardiology services excluded from prior authorization
- Emergency Room, Urgent Care, and Newborn Inpatient services excluded
Background and Delegation Summary
Neighborhood is announcing delegation of prior authorization management for Joint/Spine Surgery and Interventional Cardiology services to Evolent, effective as part of a partnership established August 21, 2025. The purpose of this change is to centralize medical management for these specialties to support clinically appropriate, high-quality care while Neighborhood continues to oversee claims adjudication.
Definitions and Exclusions
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