February 29, 2024
Dear Provider,
In keeping with our commitment of promoting continuous quality improvement for services provided to Wellcare by 'Ohana Health Plan Medicare Advantage Primary Members, Wellcare has entered into an agreement with Evolent (formerly National Imaging Associates, Inc. (NIA)), to implement a Musculoskeletal (MSK) Management program. This program includes prior authorization for non-emergent MSK procedures including: inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Wellcare by 'Ohana Health Plan Medicare Advantage Primary Members. This decision is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.
Under terms of the agreement between Wellcare and Evolent, Wellcare will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. Evolent will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with Wellcare.
Planned for an April 1, 2024 implementation, this correspondence serves as notice under your Participating Wellcare Provider Agreement of changes to the program.
Providers may begin contacting Evolent on April 1, 2024, to seek prior authorization for procedures scheduled on or after April 1, 2024.
'Ohana QUEST Integration Primary and HI Senior Medical Group IPA members are considered out of scope for the Evolent MSK program.
The following outlines the specific procedures requiring prior authorization.
MSK Surgeries: Prior authorization will be required for the following non-emergent inpatient and outpatient hip, knee, shoulder, lumbar, and cervical surgeries:
- Hip
- Revision / conversion hip arthroplasty
- Total hip arthroplasty / resurfacing
- Femoroacetabular impingement (FAI) hip surgery (includes CAM / pincer and labral repair)
- Hip surgery (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)
- Knee
- Revision knee arthroplasty
- Total knee arthroplasty (TKA)
- Partial-unicompartmental knee arthroplasty (UKA)
- Knee manipulation under anesthesia (MUA)
- Knee ligament reconstruction / repair
- Knee meniscectomy / meniscal repair / meniscal transplant
- Knee Surgery (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release / patellar realignment, articular cartilage restoration)
- Shoulder
- Revision shoulder arthroplasty
- Total / reverse shoulder arthroplasty or resurfacing
- Partial shoulder arthroplasty / hemiarthroplasty
- Shoulder rotator cuff repair
- Shoulder labral repair
- Frozen shoulder repair / adhesive capsulitis
- Shoulder Surgery (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)
- Lumbar
- Lumbar microdiscectomy
- Lumbar decompression (laminotomy, laminectomy, facetectomy, and foraminotomy)
- Lumbar spine fusion (arthrodesis) with or without decompression (single and multiple levels)
- Sacroiliac joint fusion
- Cervical
- Cervical anterior decompression with fusion (single and multiple levels)
- Cervical posterior decompression with fusion (single and multiple levels)
- Cervical posterior decompression (without fusion)
- Cervical artificial disc replacement
- Cervical anterior decompression (without fusion)
Key Provisions
- It is the responsibility of the ordering physician to obtain prior authorization for all MSK surgeries outlined above.
- Evolent does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those procedures listed above.
- Facility admissions do not require a separate prior authorization. However, the facility should ensure that an Evolent prior authorization has been obtained prior to scheduling the surgery/procedure.
Services other than the MSK surgeries outlined above will continue to follow Wellcare prior-authorization requirements for hospital admissions and elective surgeries.
We appreciate your support and look forward to your assistance in assuring that Wellcare by Ohana Health Plan Medicare Advantage Primary Members receive MSK services delivered in a quality, clinically appropriate fashion.
We will provide additional information as we get closer to the implementation date. Should you have questions at this time, please contact Wellcare Provider Services Department at 1-833-444-9088.
Sincerely,
Wellcare By 'Ohana Health Plan
