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Evolent Health Utilization Management Programs

As of 2023, National Imaging Associates (NIA) has been a subsidiary of Evolent Health. Evolent continues NIA’s tradition as a leader in managing the fastest growing, most complex areas of health, including special populations and other specialty areas of health care. Evolent's customers include, but aren’t limited to, health plans and other managed care organizations, and third-party administrators.

Evolent offers flexible, data-driven medical specialty solutions to effectively and seamlessly manage high-growth and high-cost areas of health care, improving quality, safety, and affordability. They manage services in the outpatient setting delivered by providers from multiple disciplines.

Evolent Utilization Management Programs

HMSA has a long standing partnership with Evolent (aka NIA) to provide utilization management programs.

Under the terms of HMSA’s agreement with Evolent, HMSA retains claims adjudication functions, as well as oversight of Evolent’s utilization management programs, including medical policies and procedures.

Evolent is responsible for managing precertification of services listed in the programs below.

For provider concerns not related to claims or appeals, please send your tracking/authorization number and brief summary of the issue to HMSAProviderConcerns@evolent.com.

Clinical Guidelines

Clinical guidelines that have been adapted to meet HMSA’s needs are available for reference (see www.radmd.com).

RadMD

Advanced Imaging

Evolent is contracted to provide precertification reviews of advanced diagnostic imaging services to promote the appropriate utilization in cases where traditional imaging would provide sufficient diagnostic information to treat the member or where another imaging study would be more appropriate based on the patient’s condition.

The following imaging studies require precertification through Evolent:

  • Computed Tomography (CT)/Computed Tomography Angiography (CTA)/CT Colonography
  • Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiography (MRA)
  • Magnetic Resonance Spectroscopy (MRS)
  • Functional Magnetic Resonance Imaging (MRI)
  • Multi Gated Acquisition (MUGA) Scans
  • Positron Emission Tomography (PET) Scan
  • Myocardial Perfusion Imaging (MPI)

HMSA Utilization Review Matrices

2026

2025

Additional Resources

Cardiac Solution Program

The following cardiac services require precertification through Evolent:

  • Stress Echocardiography
  • Cardiac Catheterization
  • Implantable Cardiac Devices such as Implantable Cardioverter Defibrillator (ICD) System, Pacemaker, and Cardiac Resynchronization Therapy (CRT) Pacemaker

HMSA Utilization Review Matrices

2026

2025

Additional Resources

Interventional Pain Management

The following pain management and spine surgery services require precertification through Evolent:

Musculoskeletal Surgery (Hip, Knee and Shoulder)

Joint surgeries listed on the matrix below require precertification from Evolent.

Physical Medicine (Physical Therapy, Occupational Therapy, Chiropractic)

Evolent manages the UM program for Physical Therapy, Occupational Therapy and Chiropractic Services. Applicable CPT codes listed on HMSA Medical Policy are covered when performed during visits approved by Evolent.

Training Slides [PDF]

  • Physical Therapy – Commercial/QUEST Integration/Medicare

    Evolent Physical Therapy Fast Pass Program Effective August 1, 2024

    Keeping health care affordable is necessary and HMSA is committed to continuing to evolve our processes to decrease administrative tasks for Physical Therapy providers. We’ve been working with Evolent on how to communicate clinical performance data based on the medical claims in our system. This collaboration has led to the creation of a physical therapy analytics tool. Its goal is to leverage this data as a foundation to determine physical therapy Fast Pass awards.

    Physical therapy providers will receive analytic reports of their performance and Fast Pass status. We ask them to take time to review and consider the report when received. Our Evolent partners will reach out to discuss the report and answer any questions. You may also email Evolent at HMSAProviderConcerns@Evolent.com.

    The physical therapy program Fast Pass goes into effect on Aug. 1. To be considered for the Fast Pass program, providers must:

    • Provide physical therapy services for a minimum of 20 distinct HMSA members annually.
    • Maintain a combined clinical denial rate (full and partial) of <10%.
    • Maintain outlier score percentage of ≤8%.

    Physical therapists under unique tax identification numbers who have met the criteria are eligible for a Fast Pass and aren’t required to submit prior authorization requests for physical therapy services.

    Provider performance will continue to be analyzed to determine continued Fast Pass eligibility each January and July.

  • Occupational Therapy – Commercial/QUEST Integration

  • Chiropractic – Commercial Only

CURRENT AS OF 08/03/2026

Revision History

Date Nature of Revision
08/03/2026 Migrated to new platform.