Evolent to Manage Medical and Radiation Oncology Authorizations

Beginning Jan. 1, 2027, Evolent will manage prior authorization review for medical and radiation oncology services for Highmark Commercial members in New York and Administrative Services Only (ASO)* members in Delaware, New York, Pennsylvania, and West Virginia.

Changes for Radiation Oncology

On Jan. 1, prior auths for radiation oncology services with a cancer diagnosis will be managed by Evolent. Prior auth for radiation therapy services without a cancer diagnosis will be managed by Highmark’s Utilization Management (UM) team.

Note: Prior to May 1, 2026, radiation oncology services processed as no auth required for New York providers.

Changes for Medical Oncology

In addition to radiation oncology services, prior auth requests for medical oncology services with a cancer diagnosis will also be managed by Evolent starting Jan. 1. Prior auth requests for medical oncology services without a cancer diagnosis will continue to be managed by Highmark’s UM team.

Overview

The medical and radiation oncology services program managed by Evolent rolled out earlier this year and included the following lines of business:

• Commercial fully insured; Affordable Care Act (ACA); and Medicare Advantage members in Delaware, Pennsylvania, and West Virginia
• Medicare Advantage members in New York
• Pennsylvania Child Health Insurance Program (CHIP) members

The inclusion of additional lines of business further supports Highmark’s oncology value-based care strategy to improve clinical outcomes.

No Change to Submission Process

As a reminder, practices must continue submitting initial oncology authorization requests through Highmark’s provider portal, Availity Essentials.

Our prior authorization list may be updated with additional or removed codes to reflect current oncology multi-drug regimens and support comprehensive medical necessity reviews.

For requests that go to review, providers must upload supporting clinical documentation directly to Evolent's CarePro portal, accessible at evolent.com/provider-portal.

*Note: Administrative Services Only (ASO) members who have elected to opt-in to the Evolent enhanced oncology care management program will require prior auth for medical and radiation oncology services. ASO groups that have elected to opt-out of the Evolent program will show “no authorization required” in Availity when an auth is submitted.

ASO membership includes individuals residing both inside and outside of Delaware, New York, Pennsylvania, and West Virginia.