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Evolent Partnership and Prior Authorization Changes

August 29, 2023

'Ohana Health Plan is pleased to announce its collaboration with Evolent, previously known as New Century Health, an oncology quality management company, to implement a new prior authorization program. The program will simplify the administrative process for providers to support the effective delivery of quality patient care.

Beginning October 1, 2023, oncology-related infused and oral chemotherapeutic drugs/supportive agents/symptom management medications, and radiation oncology, will require a prior authorization from Evolent before being administered in either the provider's office, outpatient hospital, ambulatory setting, or infusion center. Treatment plans will be reviewed as a whole using nationally recognized, evidence-based guidelines.

This prior authorization requirement applies to 'Ohana Health Plan Medicaid members of all ages.

We hope you will find value in the following changes coming with the Evolent partnership:

  • Real-time authorizations issued for approvable treatment plans submitted via the Evolent online portal https://my.newcenturyhealth.com
  • Ability to confirm member eligibility through the Evolent portal prior to entering a treatment plan
  • Medical Oncologists and Radiation Oncologists on staff to answer your questions
  • Telephonic Intake available for submitting treatment plans, if needed
  • Dedicated Evolent Provider Network Manager as a direct point-of-contact for any issues or questions

Authorizations issued by 'Ohana Health Plan before October 1, 2023, are effective until the authorization end date. Upon expiration, authorization requests must be submitted to Evolent. If continued authorization is not obtained from Evolent, affected claims may be denied. For services/treatment that did not require an authorization prior to October 1, 2023, an authorization may be required from Evolent for service/treatment dates on and after October 1, 2023.

Please submit claims to 'Ohana Health Plan using the prior authorization number provided in the letter from 'Ohana Health Plan, not the Evolent authorization number.

An Evolent Provider Solutions Manager will contact you soon to schedule an introductory meeting and training. Should you have any questions prior to the introductory meeting, please contact Evolent at 1-888-999-7713, Option 6 or send an email to providertraining@newcenturyhealth.com.

We look forward to offering you this program and hope that it will enhance your experience with your oncology service authorizations.

Sincerely,

'Ohana Health Plan

 

Frequently Asked Question
'Ohana Health Plan
Oncology Pathway Solutions

Q1: Who is Evolent?

A1: Evolent, previously known as New Century Health, is a comprehensive oncology quality management (OQM) company. Its platform optimizes the application of evidence-based medicine in the delivery of adult and pediatric ambulatory cancer care, oncology, and radiation oncology.

Q2: What is the 'Ohana Health Plan Oncology Pathway Solutions program?

A2: ‘Ohana Health Plan Oncology Pathway Solutions program provides prior authorization management for all infusible, injectable, and oral chemotherapy agents, supportive drugs/symptom management drugs and radiation oncology. The program emphasizes and supports the selection of Preferred Pathways for patient care and is administered by Evolent.

Q3: Is this for all 'Ohana Health Plan members?

A3: The 'Ohana Health Plan Oncology Pathway Solutions program pertains to your Medicaid members of all ages.

Precertification, preauthorization and notification requirements all refer to the same process of prior authorization.

Q4: When will the 'Ohana Health Plan Oncology Pathway Solutions program begin?

A4: The program will begin October 1, 2023.

Q5: How can a physician's office request training for this program?

A5: A Provider Solution Manager will contact you soon to schedule an introductory meeting and training. Should you have any questions prior to the introductory meeting, please contact Evolent at 1-888-999-7713, Option 6, or send an email to providertraining@newcenturyhealth.com.
 

Prior authorization

Q6: What are some key features of the program?

A6:  The online provider portal is always available, offering the following:

  • Real-time authorizations for treatment care pathways
  • Reduced documentation requirements
  • View of real-time status of authorization requests
  • Eligibility verification

Supportive telephonic authorization staff available at 1-888-999-7713,

  • Medical Oncology - Option 2
  • Radiation Oncology - Option 3
    • Monday - Friday, 5:00 AM - 5:00 PM PST (Fully Staffed)
    • Saturday, 5:00 AM - 6:00 PM PST (Limited Staff) *
    • Sunday, 6:00 AM - 3:00 PM PST (Limited Staff) *
    • *After hours call coverage available from Monday - Friday 6PM - 5AM PST
  • Quick turnaround time on authorization requests submitted via portal or phone
  • Physician Discussions with medical oncologists or radiation oncologists
  • Evolent is a National Comprehensive Cancer Network (NCCN) licensee of the Drugs and Biologics Compendia. It uses nationally recognized, evidence-based treatment guidelines
  • Evolent provider representatives are available for support as needed.

Q7: What is the transition of care process?

A7: Authorizations previously issued by 'Ohana Health Plan before October 1, 2023, will be effective until the authorization expiration date. Requests for new treatment and/or changes in treatment on or after October 1, 2023, must be submitted to Evolent for preauthorization.

Q8: Who should obtain prior authorization?

A8: The physician ordering chemotherapeutic drugs, supporting agents or radiation oncology for the treatment of cancer or related hematologic diseases must request prior authorization through Evolent.

Q9: How do I obtain prior authorization?

A9:  Submit chemotherapy requests to Evolent via the following methods:

Q10: Which drugs require prior authorization?

A10: 'Ohana Health Plan Oncology Pathway Solutions Program, administered by Evolent, requires prior authorization management for chemotherapeutic drugs, symptom management drugs, supporting agents and radiation oncology for members with a diagnosis code included in the following range:

Cancer = C00 – D09, D37-D44, E34.0

Hematology Diagnosis = D45-D49, D59.10-D59.19, D61.81, D61.82, D63.0, D63.8, D64.2-D64.3, D64.81, D64.89, D64.9, D68.59, D69.3, D69.41, D69.59, D69.6, D69.8, D69.9, D70.1-D70.9, D72.8, D72.9, D73.81, D73.9, D75.1, D75.81, D75.82

N&V = R11

Q11. Why did my service not require a prior authorization before 10/1 but after 10/1 the same service now requires a prior authorization?

A11: Evolent's clinical reviewers are reviewing regimens and treatment requests to ensure they have a complete clinical picture of the member's entire treatment plan. For services within Evolent's scope, medications and services that may not have previously required an authorization will now require an authorization by Evolent.

Q12: Which specialties are included in the 'Ohana Health Plan Oncology Pathway Solutions program?

A12: Medical specialties providing cancer care and its supportive services including Medical Oncology, Hematology, Urology, Surgical Oncology, Neurological Oncology, Gynecologic Oncology, Radiation Oncology, and Pediatric Oncology will submit their chemotherapy and radiation oncology prior authorizations through Evolent.

Q13: Who at Evolent will be reviewing chemotherapy requests?

A13: Evolent Medical Reviewers are licensed medical oncologists and radiation oncologists are not incentivized to issue denials, as they use nationally recognized clinical guidelines when performing reviews. These guidelines are available at https://my.newcenturyhealth.com or by contacting Evolent’s Utilization Management at 1-888-999-7713, Option 2.

If the request does not meet evidence-based treatment guidelines, Evolent may request additional information or initiate a peer-to-peer conversation with the requesting provider.

Q14: What will the Evolent authorization look like, and how long is it valid?

A14: The Evolent authorization will start with "AR" followed by at least four digits (e.g., AR1000). It is valid for the duration indicated on the Medication Request Authorization (MRA) or Service Request (RA).

Please submit claims to 'Ohana Health Plan using the prior authorization number provided in the letter from 'Ohana Health Plan, not the Evolent authorization number.

Q15: What place of service does this prior authorization review process include?

A15: The Oncology Pathway Solutions program applies to services rendered (e.g., chemotherapy administration) in an outpatient setting, which could include the physician’s office, infusion centers and outpatient hospital locations.

Q16: Does a prior authorization guarantee payment?

A16: No, a prior authorization does not guarantee payment for services. Payment of claims is dependent on eligibility, covered benefits, provider contracts, and correct coding and billing practices. For specific details, please refer to your Provider Manual.

Q17: What will happen if the physician does not request and obtain an authorization?

A17: If a required authorization is not obtained, 'Ohana Health Plan may deny payment for the relevant drugs. Members cannot be held responsible or billed for denied charges/services.