To ensure that members receive the most appropriate and effective radiology procedure, for requests received beginning Jan. 1, 2025, Point32Health will require requesting providers to submit clinical documentation for outpatient advanced imaging services for our Tufts Health Plan Commercial and Tufts Health Public Plans members.
Evolent (formerly National Imaging Associates, Inc.), who administers our advanced imaging authorization program, will review pertinent medical records to validate that medical necessity criteria for the requested study have been met. There are no changes to the procedures that require prior authorization, and the clinical guideline criteria used to determine medical necessity will remain the same.
Submitting documentation
For all requests that are not approved at intake, clinical documentation must be submitted before Evolent can make a final authorization determination. Multiple outreach attempts are made prior to an adverse decision, but if the required clinical information is not submitted within the allowable timeframe (typically 10-15 days), Evolent will deny the request.
The process to submit documentation to Evolent is not changing. You can submit the required documentation either electronically or by fax. If you use the online provider portal (www.RadMD.com) to submit your authorization request, the system will automatically specify what information is needed and prompt you to upload it.
If you are requesting authorization by phone (866-642-9703 for Tufts Health Plan Commercial, 800-207-4209 for Tufts Health Public Plans), Evolent will fax you a document specifying which records are necessary and will include a bar-coded customized fax coversheet for your use.
Clinical guidelines, provider tip sheets, prior authorization checklists, and other resources can be found at www.RadMD.com. For more information on how to submit clinical documentation, view this training video.