Q: What is Evolent Healthcare?
A: Evolent Healthcare was established in 1985 as Health Management Services, Inc., as a chiropractic provider network management organization. We have expanded into managing other specialty networks, including acupuncture, massage therapy, physical therapy, occupational therapy, and speech therapy. Magellan manages provider networks by providing credentialing, administrative services, utilization management, quality management and claims processing services. We contract with a variety of payers including PPO’s, HMO’s, and other health plans who access and utilize our services for their enrollees.
Q: What is the relationship between Evolent Healthcare and the actual insurance companies, TPA’s, HMO’s, PPO’s, and other payers?
A: Magellan has established provider networks of various specialty providers. Evolent’s role in contracting these networks includes provider selection, credentialing, re-credentialing, quality improvement, utilization management, and claims administration. However, we are not the insurance company. Evolent contracts with PPOs, HMOs and insurance companies to manage provider network services for their plan enrollees. The payers, not Evolent, make final payment determinations, maintain member eligibility, and determine and apply the benefit plan design.
Q: What are the benefits of joining an Evolent Healthcare network?
A: Evolent Healthcare providers are the in-network providers for patients under our payers/plans and all plans have benefit differential encouraging the use of in-network providers. Network providers are listed in the Provider Directories for the various plans. So, network participation can increase your patient base. Another benefit is access to information. As part of our Quality Assurance initiatives you will be given information on various indicators comparing your practice to all other Evolent Healthcare providers. We share other educational information as well through our Provider Manual and newsletters.
Q: Is there any cost to join the Evolent Healthcare network?
A: There is no charge for participating in an Evolent Network.
Q: How do I start the process of joining the Evolent Healthcare network?
A: You may compete the Prospective Provider Profile available on this web site under each specialty area. The completion of this form does not guarantee providership within an Evolent Healthcare network. If you appear to meet our credentialing requirements and if there is a need for a provider in your area, we will forward a credentialing application to you.
Q: How do participating providers submit claims and get paid?
A: Participating providers submit claims to Evolent Healthcare who, in turn, submits them to the appropriate payer. Evolent Healthcare is paid for these claims and, in turn, pays the provider according to the applicable contracted rate.
Q: Once I’m a participating provider, do I have to complete any special paperwork other than submitting claims?
A: Rehab providers in general do not need to submit additional paperwork. If a provider does not meet Quality and Utilization Management standards, they may be asked to submit documentation for peer review.
Q: What services are “covered services”?
A: Benefit plan coverage varies by each Payer and Plan according to the benefit structure agreed upon by the employer or other plan purchaser and the Payer. Contact each health plan directly as identified on the patient identification card to verify the specific benefit and eligibility information of each Plan and patient. Magellan does not maintain benefit information.
Q: How am I reimbursed for non-covered services?
A: Non-covered services are the responsibility of the patient upon their prior-written acceptance of such.