How Evolent prior authorization works for each health plan

Evolent reviews prior authorization requests on behalf of health plans for advanced imaging, cardiology, musculoskeletal care, physical medicine (physical, occupational and speech therapy and chiropractic care) and oncology. Each plan decides which services it sends to Evolent and which portal and phone line its providers use, so the same service can go to Evolent for one patient and to the plan itself for the next.

The NIA and New Century Health programs have used one name, Evolent Specialty Services, since January 1, 2024, according to an Ambetter of North Carolina notice. A Medicaid managed care plan or Medicare Advantage plan that hands reviews to a vendor keeps ultimate responsibility for its contract, under 42 CFR 438.230 and 422.504, so for those plans their own rules and deadlines still apply to Evolent’s reviews.

At a glance

• Wellcare sends cardiology and oncology requests to Evolent’s my.newcenturyhealth.com portal.
• Magnolia Health has used Evolent for PT, OT and speech therapy since July 1, 2023.
• An Evolent therapy approval is a number of visits within a validity period.
• BCBS South Carolina moves more services to Evolent on November 1 and December 1, 2026.
• Superior HealthPlan moved some Texas Medicaid and CHIP therapy reviews off Evolent on July 1, 2026.

Which health plans use Evolent, and for what

Each plan’s own notices list the services it sends to Evolent. These plans show how much the setup differs:

Plans also move work away from Evolent. Superior HealthPlan moved PT, OT and speech therapy reviews for its Texas Medicaid STAR, STAR+PLUS (non-waiver) and CHIP members to Centene Management Company on July 1, 2026, while therapy for Ambetter from Superior HealthPlan stays with Evolent, according to its notice of April 1, 2026. For Wellcare’s own lists and forms, see the Wellcare prior authorization guide.

How to send a request to Evolent

The portal depends on the plan. Most imaging, musculoskeletal, physical medicine and pain programs use RadMD.com, and so do BCBS South Carolina’s cardiology reviews. Wellcare’s cardiology and oncology requests go to my.newcenturyhealth.com, and Highmark’s initial oncology requests go through Availity Essentials before Evolent’s review. For how Availity requests work, see the Availity prior authorization guide.

At Point32Health’s plans, the ordering provider is responsible for getting the approval, and the rendering provider must confirm it and have the authorization number before the service. For therapy, the ordering provider is the treating therapist who does the initial evaluation, according to a Maryland Physicians Care FAQ (June 2024). Evolent’s Magnolia Health training says an office that both orders and performs services should ask for ordering-provider access on RadMD, which lets it request approvals and see their status. The Maryland Physicians Care FAQ says RadMD.com can’t take medically urgent or expedited requests during business hours, so those go to Evolent’s call center by phone.

Evolent prior authorization phone numbers by plan

The Evolent prior authorization phone number is set by each plan. Wellcare Medicare Advantage uses 1-800-424-5388, option 1, for cardiology and oncology, and other plans list theirs in their own Evolent notices:

Evolent prior authorization forms

Evolent requests are made in the plan’s portal, by phone or, for some programs, by fax, so there is no general Evolent request form. Clinical documents can be uploaded to RadMD.com or faxed to Evolent at 1-800-784-6864 with a case-specific coversheet, as Evolent’s Magnolia Health and Maryland Physicians Care therapy programs describe.

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What PT, OT and speech therapy requests need

The initial evaluation usually needs no approval, and the request follows within a set window. Magnolia Health and Maryland Physicians Care allow 5 business days from the evaluation. At Absolute Total Care, initial PT, OT and speech therapy evaluation codes need no approval for participating providers, though other codes billed the same day do, and providers have up to 10 calendar days after the initial visit to request approval, according to its FAQ (August 2024). When the request is on time, Evolent can backdate the authorization to the evaluation date.

In Evolent’s program for Magnolia Health, an approval is a number of visits within a validity period, and each date of service counts as a visit. A 30-day extension of the validity period can be requested. A subsequent request needs these documents, according to Evolent’s Magnolia Health training (September 2025):

• The most recent evaluation or re-evaluation, if not sent before
• The latest progress note
• An updated plan of care
• Two to three recent daily notes

Chiropractic care differs by plan. Ambetter from Sunshine Health doesn’t send physical therapy from chiropractors to Evolent, while Maryland Physicians Care has required Evolent approval for chiropractors giving physical therapy to members 21 and older since March 1, 2021 (FAQ, as of June 2024).

Therapy practices hand this visit-by-visit work to Silna. Zion Physical Therapy averages a 4-day authorization turnaround with Silna, according to its case study (March 2025).

Evolent review times and the plan’s deadline

For Medicare Advantage and Medicaid plans, the plan’s legal limit applies to Evolent’s reviews. Some Evolent programs also state their own review times.

Marketplace plans are outside the decision limits in CMS’s 2024 prior authorization rule. The federal claims rules, which apply to them through 45 CFR 147.136, allow up to 15 days for a non-urgent request and 72 hours for an urgent one. For the Medicare and Medicaid rules in full, see the guides to Medicare prior authorization and Medicaid prior authorization.

For outpatient imaging at Maryland Physicians Care, Evolent generally decides within 2 business days of a request with full clinical documentation, according to its imaging FAQ (June 2024). For therapy at Magnolia Health and Maryland Physicians Care, reviews are generally done within two or three business days of sufficient clinical information. These times start once the clinical information is complete, while the federal limits run from the request.

What happens after an Evolent decision

NH Healthy Families and Ambetter from NH Healthy Families extended Evolent approvals for advanced imaging, interventional pain management and musculoskeletal care from 30 to 60 days, effective March 19, 2026, according to their notice of April 6, 2026. At Maryland Physicians Care, an imaging approval is valid for 60 days from the date of the request. Florida Blue’s Medicare notice says the codes billed on the claim must match the codes Evolent authorized, or the services are denied.

After a denial, a re-review with new information is possible within 5 business days at Magnolia Health and within 2 business days at Maryland Physicians Care, before a formal appeal. For Absolute Total Care’s Medicare plans, a peer-to-peer discussion must take place before a final determination, a rule in place since August 5, 2024. At Magnolia Health and Absolute Total Care, appeals go through the health plan, as the denial letter explains. The steps are in the guide to appealing a prior authorization denial.

A patient who joins a new Medicare Advantage coordinated care plan mid-treatment gets a transition period of at least 90 days for that course of treatment, under 42 CFR 422.112(b)(8).

What Silna does on Evolent requests

For each request, Silna checks whether the patient’s plan sends the service to Evolent and through which portal, then submits it with the clinical documents the program asks for and follows up until a decision comes back. For therapy, it tracks visit counts and validity dates and sends the subsequent request with the progress and daily notes Evolent asks for. Its insurance monitoring flags lost coverage or a new plan. For the other benefit managers, see the guides to eviCore and Carelon prior authorization.

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Key terms

RadMD

Evolent’s provider portal for most imaging, musculoskeletal, physical medicine and pain programs, formerly the NIA portal.

CarePro

Evolent’s provider portal for oncology and some cardiology programs, at my.newcenturyhealth.com, formerly the New Century Health portal.

Ordering provider

The provider who requests the prior authorization, such as the treating therapist for therapy.

Rendering provider

The provider who performs the service and confirms the approval before it.

Physical medicine

Evolent’s program for physical, occupational and speech therapy and chiropractic care.

Frequently Asked Questions

Is NIA the same as Evolent?

NIA’s programs have used the Evolent name since January 1, 2024, along with New Century Health’s. Its portal is now RadMD, and New Century Health’s is CarePro.

Do I need a form to request an Evolent prior authorization?

No general form exists. Requests go through the plan’s Evolent portal or by phone, and clinical documents are uploaded to the portal or faxed with a case-specific coversheet.

What phone number do I call for an Evolent prior authorization?

Each plan publishes its own. BCBS South Carolina uses 866-500-7664 for BlueCross members, and Florida Blue’s Medicare plans use 1-888-854-2098 for cardiology and oncology.

Does physical therapy need approval from Evolent?

Only when the patient’s plan sends therapy to Evolent, as Magnolia Health has since July 1, 2023. Initial evaluations usually need no approval, and the approval that follows is a number of visits within a validity period.

How quickly does Evolent review a request?

It depends on the program. Evolent generally decides outpatient imaging at Maryland Physicians Care within 2 business days of full clinical documentation, and therapy at Magnolia Health within two or three business days of sufficient clinical information. The plan’s legal limit still applies, such as 7 calendar days for a standard Medicare Advantage request.

This article is general educational information and does not give medical, legal or insurance advice. Health plans change which services they send to Evolent during the year, so check the patient’s plan notice before you send a request.

About the author

Jeffrey Morelli

Jeffrey Morelli is the Co-Founder and CEO of Silna Health, the first Care Readiness Platform built to remove the administrative barriers that delay care. Silna automates benefit checks, eligibility, and prior authorizations across 1,000+ payors, and is backed by $27M from Accel and Bain Capital Ventures. Before Silna, Jeff spent a decade in San Francisco building and scaling products for highly regulated industries, including leading go-to-market at Truework (Series C, acquired by Checkr).

Last updated: October 20, 2026.