Evolent, formerly New Century Health (NCH), is a comprehensive quality management company that EmblemHealth has designated as its utilization review agent. Evolent offers collaboration and peer-to-peer discussions with oncologists’ and physicians’ offices. They have a provider web portal where you can request preauthorizations, select treatment care pathways, obtain help with documentation, and more.
EmblemHealth Oncology Drug Management Program
Reviewed: 04/29/2025
02/02/2023
As of Jan. 1, 2021, Evolent handles utilization management for most oncology-related chemotherapeutic drugs and supportive agents when delivered in the physician’s office, outpatient hospital, or other ambulatory setting. Evolent emphasizes and supports the selection of Preferred Pathways for adult oncology patient care.
Evolent manages medical specialties providing cancer care and its supportive services, including medical oncology, hematology, urology, and gynecologic oncology.
Evolent will not manage:
- Members under 18 years of age.
- Most EmblemHealth Plan, Inc. (formerly GHI) members.
- HealthCare Partners managed members.
The following services are excluded from the Evolent program:
- Requests for patients under 18 years of age.
- Equipment requests (e.g., IV pump).
- Inpatient requests.
- Hemophilia drugs.
- Bone marrow transplants.
- Inpatient chemotherapy services.
- ESRD patients.
- Clinical trials.
- Radiopharmaceuticals.
- All places of treatment and services not specifically listed above.
Register to use Evolent’s provider portal which is always available and offers:
- Real-time authorizations for oncology treatment care pathways.
- Reduced documentation requirements.
- View of real-time status of preauthorization requests.
- Eligibility verification.
You may request training on the provider portal. You may also contact Evolent Network Operations at 888‑999‑7713, option six, 8 a.m. to 8 p.m., Monday through Friday.
Preauthorization
The Evolent program offers many benefits including:
- Peer-to-peer consultations by medical oncologists.
- Quick turnaround time on preauthorization requests submitted via portal, fax, or phone.
Evolent’s provider portal is always available, offering:
- Real-time authorizations for oncology treatment care pathways.
- Reduced documentation requirements.
- View of real-time status of preauthorization requests.
- Eligibility verification.
You can fax preauthorization request forms to 877-624-8602. Supportive telephonic authorization staff is available at 888-999-7713, 8 a.m. to 8 p.m., Monday through Friday.
An Evolent provider representative is available for support as needed.
Evolent medical reviewers are licensed medical oncologists.
If the request does not meet evidence-based treatment guidelines, Evolent may request additional information or initiate a peer-to-peer conversation with the requesting provider.
The reviewers use nationally recognized clinical guidelines when performing reviews. These guidelines are available in Evolent’s provider portal or by contacting Evolent’s Utilization Management at 888-999-7713, option six, 8 a.m. to 8 p.m., Monday through Friday.
The preauthorization review process applies to services rendered (e.g., chemotherapy administration) in an outpatient setting, which could include:
- Physician’s office.
- Infusion centers.
- Outpatient hospital locations.
- Other ambulatory care settings.
- Commercial members: Call 844-516-3324, 24 hours a day, seven days a week, 365 days a year.
- Medicare members: Call 877-920-1470, 24 hours a day, seven days a week, 365 days a year.
- Medicaid members: Call 888-281-5539, 24 hours a day, seven days a week, 365 days a year.
- You can also fax requests to 877-251-5896.
Express Scripts Medical Drug Reviews for:
Commercial, Medicare, and Medicaid members: call 877-681-9866, 8 a.m. to 7 p.m., Monday through Friday, or fax to 866-896-1209.
Claims
EmblemHealth is responsible for grievance and appeals.
For information on grievance and appeals processes, see the following chapters in the EmblemHealth Provider Manual:
JP 66040 6/24