Advance Imaging & Spine and Pain Services

Blue Shield of California is contracted with Evolent to provide medical necessity reviews and prior authorization for advanced imaging, and spine and pain management.

Contacts

Authorization requests and status information can be obtained by calling the Evolent telephone call center. Authorization status for a provider's patients can also be checked online at the Evolent website. The website also provides additional information about Evolent and its services.

 Phone:(888) 642-2583

Evolent reviews are not required for:

• Blue Shield HMO members (other than those with a Blue Shield directly contracted PCP or Trio HMO members with a virtual PCP), but authorization from the member's IPA or medical group may be needed
• Federal Employees Program (FEP) members
• Members covered by Blue Cross Blue Shield plans of other states
• Members covered by certain employer ASO plans
• Medicare

NOTE: Within five days before the actual date of service, providers MUST confirm with Blue Shield that the member's health plan coverage is still in effect.

Blue Shield reserves the right to revoke authorizations prior to services being rendered based on cancellation of the member's eligibility. Final determination of benefits will be made after review of the claim for limitations or exclusions.

The goal of this advanced imaging and spine and pain management program is to improve the quality, accountability, and cost of services to our members.

To accomplish this goal, Evolent coordinates with referring providers to assure advanced imaging and spine and pain services are appropriate compared to national standard clinical protocols.

Specific services

The following outpatient non-emergency services are reviewed by Evolent:

• CT (computerized axial tomography), all examinations
• MRI (magnetic resonance imaging), all examinations
• MRA (magnetic resonance angiography), all examinations
• PET (positron emission tomography), all examinations
• Cardiac nuclear medicine studies (e.g., nuclear cardiac stress test)
• Outpatient and non-emergency inpatient lumbar and cervical spine surgery
• Outpatient interventional pain management

The following services are not reviewed by Evolent:

• Hospital emergency room
• Inpatient advanced imaging services
• Observation bed
• Out of state services
• Outpatient surgery - incidental advanced imaging