Prior authorization for non-emergent joint/spine surgery and interventional cardiology
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This notice informs providers that, for Neighborhood Health Plan of Rhode Island members, Evolent will manage prior authorization for specified non-emergent joint/spine surgeries (Medicaid and Medicare lines) and non-emergent interventional cardiology for adults 19+; Commercial line is excluded. Providers must obtain authorization via Evolent beginning Jan 1, 2026 (requests accepted) with authorizations required for dates of service on or after Feb 1, 2026.
Evolent will manage prior authorization for Joint/Spine Surgery and Interventional Cardiology for Medicaid and Medicare lines of business; Commercial line excluded.
Authorization required for non-emergent Joint/Spine Surgeries for dates of service on or after February 1, 2026 with requests accepted starting January 1, 2026.
Authorization required for non-emergent Interventional Cardiology services for adults 19 years or older for dates of service on or after February 1, 2026; emergent services are excluded.
Providers must use Evolent's RadMD portal to submit authorization requests; portal access can be requested prior to Jan 1, 2026.
Coverage Criteria
Authorization conditions
Covered when the following authorization and operational conditions are met:
Emergent interventional cardiology services are excluded from the prior authorization requirement.
Evolent will manage authorizations while Neighborhood continues claims adjudication.
Claims may be denied if authorization is not secured.
This delegation does not apply to Neighborhood's Commercial line of business; Evolent will manage prior authorization only for the Medicaid and Medicare lines. Emergent Interventional Cardiology services are excluded from the authorization requirement. Providers should note that a complete list of CPT codes and service descriptions requiring authorization is available on Neighborhood's website.
Coding and Code References
| No codes listed |
What Providers Must Do
Prior Authorization Required
Effective for dates of service on or after February 1, 2026, prior authorization is required for the listed non-emergent Joint/Spine Surgery and non-emergent Interventional Cardiology services. Providers may begin submitting authorization requests starting January 1, 2026. Prior authorization is required for non-emergent care only; emergent Interventional Cardiology services are excluded.
- Joint/Spine Surgery and specified spine procedures (see full code list on the portal)
- Non-emergent Interventional Cardiology services for members age ≥19 (emergent services excluded)
- Authorization required for dates of service on or after 2026-02-01; submission may begin 2026-01-01
Portal Registration and Use
Register for Evolent's provider portal at RadMD.com. Complete the portal registration process to request authorizations and view authorization status. While portal access can be requested at any time, authorization submission will only be accepted starting January 1, 2026. Neighborhood strongly encourages providers to register and become familiar with the portal before that date.
- Portal URL: RadMD.com
- Authorization submissions accepted beginning 2026-01-01
Authorization Confirmation and Denial Risk
Before rendering any services, ordering and rendering providers are responsible for obtaining required authorizations for Interventional Cardiology and Joint/Spine Surgery services. Confirm authorization has been obtained by checking RadMD.com or by calling Evolent at 1-877-469-7949. Claims may be denied if authorization is not secured.
- Confirm authorization via RadMD.com or phone: 1-877-469-7949
- Claims may be denied if authorization is not obtained
Provider Action Notes
Operational notes for providers: Neighborhood continues to oversee claims adjudication. Evolent will manage the medical management programs for Joint/Spine Surgery and Interventional Cardiology for Medicaid and Medicare lines (Commercial not included). For the complete list of CPT codes and service descriptions requiring authorization, refer to the RadMD portal.
- Evolent manages medical management; Neighborhood retains claims adjudication
- Commercial line of business is not included in the delegation
- Full CPT/service lists available on RadMD.com
Background
Neighborhood has delegated management of utilization review and prior authorization for specified Joint/Spine Surgery and Interventional Cardiology services to Evolent. Under this arrangement, Evolent will manage authorizations while Neighborhood continues to perform claims adjudication.
Providers may begin submitting authorization requests to Evolent starting January 1, 2026, and authorizations will be required for dates of service on or after February 1, 2026. For Interventional Cardiology, the delegation applies to adults aged >= 19 years, and emergent interventional cardiology services remain excluded from prior authorization.
Definitions
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