Medical Policies and Claim Editing System for 2020 Individual Plans

  • September 19, 2019

    Effective January 1, 2020, Evolent Health will begin managing many of the operational responsibilities for our Individual plans. These include medical management, as well as editing and paying claims. Because of this, we need to make you aware of a few changes. These changes are only for our 2020 Individual plans.

    • Medical Policies: There will be 37 new medical policies for our Individual plans. You can review the new policies on our policy page. Additionally, Evolent Health will use InterQual® criteria when reviewing certain services. You can view the list of services that the criteria will apply to in policy 10.01.530, titled Services Reviewed Using InterQual® Criteria.
    • Payment policies: These will stay the same. We’ll be using our existing Premera payment policies for our Individual plans.
    • Claim processing: Claims for Individual plans will be adjudicated by Evolent Health. You may notice slight differences in allowed amounts when compared to Premera due to things like rounding, edits, or fee schedule update timing.
    • New code list: We’ll have a separate code list for Individual plans. Most services will now require prior authorization. You can view the new code list for details on review requirements.

    We have a great deal of important information to share with you about our Individual plans. We’ll continue to update you through Provider News this fall. Please make sure that everyone in your organization is signed up to receive Provider News.

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