CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Delegation and Prior Authorization for Joint/Spine Surgery and Interventional Cardiology Services

Delegation of medical management for Joint/Spine Surgery and Interventional Cardiology to Evolent for Medicaid and Medicare members; establishes prior authorization for specified non-emergent procedures effective Feb 1, 2026 (requests accepted starting Jan 1, 2026). Commercial line excluded.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDelegation and Prior Authorization for Joint/Spine Surgery and Interventional Cardiology Services

Policy CodePolicy N/A

Change TypeDelegation and new prior authorization requirements

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionOrdering or rendering providers must obtain prior authorization from Evolent via RadMD.com or by calling Evolent before providing non-emergent Joint/Spine Surgery and non-emergent Interventional Cardiology services for applicable members.

SourceLink

POLICY UPDATE CHANGES

Delegation of prior authorization and clinical management for Joint/Spine Surgery and Interventional Cardiology services to Evolent for Medicaid and Medicare lines of business.

Prior authorization requirement for non-emergent Interventional Cardiology services for adults 19 years and older.

Prior authorization requirement for a broad set of non-emergent Joint and Spine surgeries.

2026-02-01Effective date for required prior authorizations

2026-01-01Date providers may begin submitting prior authorization requests

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Prior Authorization Requirements

Prior Authorization Required — Joint/Spine Surgery

Prior authorization required for non-emergent joint and spine surgeries for Medicaid and Medicare members; providers may submit requests starting January 1, 2026 for dates of service on or after February 1, 2026.

ALL of the following must be met

Service is a non-emergent Joint or Spine surgical procedure within the delegated categories (hip, knee, shoulder, spinal procedures as listed).
Member is covered under Neighborhood's Medicaid or Medicare line of business (Commercial is excluded).
Prior authorization request is submitted to Evolent via RadMD portal or phone prior to service (requests accepted starting 2026-01-01).
Claims may be denied if authorization is not secured.

Prior Authorization Required — Interventional Cardiology

Prior authorization required for non-emergent interventional cardiology services for adults 19 years of age or older.

ALL of the following must be met

Patient age is 19 years or older.>= 19 years
Service is a non-emergent interventional cardiology procedure included on the CPT/code list requiring authorization.
Prior authorization request is submitted to Evolent via RadMD portal or phone prior to service (requests accepted starting 2026-01-01).
Emergent interventional cardiology services are excluded from prior authorization.

Affected Procedure Categories and Codes

Interventional Cardiology CPTs requiring authorizationCPTCovered

A complete list of CPT codes and service descriptions requiring authorization is provided to providers (not reproduced in this notice).

What Providers Must Do

Prior Authorization

Obtain prior authorization from Evolent

Ordering or rendering providers must obtain prior authorization from Evolent prior to rendering non-emergent Joint/Spine Surgery and non-emergent Interventional Cardiology services for applicable members. Requests may be submitted beginning January 1, 2026; prior authorizations are required for dates of service on or after February 1, 2026. Submit requests via the Evolent RadMD portal or by phone.

Portal: RadMD.com
Phone: Call Evolent (see RadMD or Provider Services for number)

Documentation Required

Confirm authorization before rendering

Rendering providers should confirm that an authorization has been obtained before providing the service by checking the RadMD portal or calling Evolent at 1-877-469-7949. Claims may be denied if authorization is not secured.

Delegation and Management Context

Neighborhood Health Plan of Rhode Island has delegated medical management for Joint/Spine Surgery and Interventional Cardiology services to Evolent for the plan's Medicaid and Medicare members. The Commercial line of business is excluded from this delegation. This partnership is intended to support clinically appropriate, high-quality care while maintaining Neighborhood's oversight of claims adjudication; Evolent will be responsible for prior authorizations and clinical review for the delegated services.

Evolent will accept prior authorization requests via its online portal (RadMD.com) or by phone beginning January 1, 2026, for services with dates of service on or after the effective date of February 1, 2026. Providers must obtain prior authorization from Evolent before rendering applicable non-emergent Joint/Spine and Interventional Cardiology services for covered Medicaid and Medicare members.

Neighborhood and Evolent will provide provider support and education, including a new clinical medical policy effective January 1, 2026, FAQs, access to the Evolent provider website, and scheduled provider education webinars to help practices register for RadMD and understand authorization requirements. Providers can request portal access at RadMD.com at any time, but may not submit requests until January 1, 2026.

Reminder communications will clarify operational details and exclusions (for example, emergent Interventional Cardiology, Emergency Room, Urgent Care, and newborn inpatient services do not require prior authorization). Providers with questions can contact Provider Services as noted in the provider communications.

Key Definitions

Defined term

Non-emergentServices that are scheduled or not performed in an emergent setting; emergent services (including emergent interventional cardiology) are excluded from prior authorization requirements.

ScopeApplies to non-emergent Joint/Spine Surgery and non-emergent Interventional Cardiology services delegated to Evolent for Neighborhood's Medicaid and Medicare lines of business.

ExclusionsEmergent interventional cardiology services and services in emergent settings are excluded from prior authorization requirements.

Policy Changes

2026-02-01effective_date

Effective date for required prior authorization: Prior authorization required for non-emergent Joint/Spine Surgery and non-emergent Interventional Cardiology services for applicable members, with prior authorization effective for dates of service on or after February 1, 2026 (Commercial line excluded). Delegation of prior authorization and clinical management for Joint/Spine Surgery and Interventional Cardiology services to Evolent for Medicaid and Medicare lines of business.

2026-01-01implementation_start_for_requests

Providers may begin submitting prior authorization requests to Evolent via RadMD (requests accepted starting January 1, 2026); a new clinical medical policy and provider resources (FAQs, webinars) will be available effective January 1, 2026.

2025-11-01 to 2025-12-31

At-a-Glance Policy Details

Key implementation dates and scope

Effective date for required prior authorizations2026-02-01

Date providers may begin submitting prior authorization requests2026-01-01

Age threshold for Interventional Cardiology prior authorization19+ (applies to adults 19 years of age or older)

Lines of business includedMedicaid, Medicare

Line of business not includedCommercial excluded