Evolent Health (formerly NIA)

The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

PA Health and Wellness oversees the NIA program and is responsible for claims adjudication. NIA manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.

Prior authorization is required for the following outpatient radiology procedures:

• CT/CTA/CCTA
• MRI/MRA
• PET Scan

KEY PROVISION:

Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.

Go to the NIA website for more information.

PA Health and Wellness, in collaboration with NIA Magellan, will launch a cardiac imaging program to promote health care quality for patients with possible cardiac disease. 

Under this program, prior authorization will be required for certain cardiac studies to determine if the cardiac test or procedure is the most appropriate next step in a patient’s diagnosis or treatment—and to recommend an alternate approach when indicated. By supporting the most efficient diagnosis and management of cardiac disease, NIA Magellan addresses unnecessary procedures and promotes the least invasive, most medically appropriate approach.

NIA Magellan has developed proprietary utilization management guidelines for these cardiac modalities. These consensus-based guidelines draw on current literature, American College of Cardiology (ACC) appropriateness criteria, recommendations from the American Heart Association, and input from our Cardiac Advisory Board and other experts. NIA’s guidelines are transparent and available throughout their programs.  NIA also includes references to the Choosing Wisely campaign by the American Board of Internal Medicine (ABIM) Foundation, which provides specialty society considerations for the selection of appropriate tests. 

In addition to the other procedures that currently require prior authorization for members, prior authorization will be required for the following cardiac procedures:

• Myocardial Perfusion Imaging (MPI)
• MUGA Scan
• Echocardiography
• Stress Echocardiography

KEY PROVISION:

Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.

Go to the NIA website for more information.

To help ensure that physical medicine services (physical, occupational and speech therapy) provided to our members are consistent with nationally recognized clinical guidelines, PA Health and Wellness has partnered with NIA to manage the post service utilization review of our members’ outpatient rehabilitative and habilitative physical, occupational and speech therapy services.

Physical, occupational and speech therapy services claims will be reviewed by NIA peer consultants to determine whether the services met/meet PA Health and Wellness policy criteria for medically necessary and medically appropriate care.  These determinations are based on a review of the objective, contemporaneous, clearly documented clinical records. These reviews help PA Health and Wellness determine whether such services (past, present, and future) are medically necessary and otherwise eligible for coverage.

NIA may request clinical documentation to support the medical necessity and appropriateness of the care. Prior authorization of therapy services is not required. There is no need to send patient records in advance. NIA will notify you if records are needed.  If records are necessary, it is important you know that PA Health and Wellness cannot adjudicate your claims until the necessary information is received and reviewed. If the documentation received fails to establish that care is/was medically necessary PA Health and Wellness may deny payment for services and future related therapy services thereafter. Additionally, if requested records are not received in an appropriate amount of time, claims will be denied due to lack of information. 

Under terms of the agreement between PA Health and Wellness and NIA, PA Health and Wellness, will oversee the NIA Therapy Management program and continue to be responsible for claims adjudication.  If NIA therapy peer reviewers determine that the care provided fails to meet our criteria for covered therapy services, you and the patient will receive notice of the coverage decision.  

Ambetter from PA Health and Wellness Physical Medicine QRG - September 2, 2020 (PDF)

Ambetter from PA Health and Wellness Physical Medicine Provider FAQ - September 2, 2020 (PDF)

Ambetter from PA Health and Wellness Physical Medicine Tip Sheet Checklist (PDF)

NIA Expansion Letter (PDF)

WellCare Medical Specialty Solutions Provider Webinar Invite - November, 15 2021 (PDF)

WellCare Medicare IPM Provider Webinar Invite - November 15, 2021 (PDF)

WellCare Medicare Physical Medicine Provider Webinar Flyer - November 15, 2021 (PDF)