Compliance & Regulatory

Privacy Notice

For a copy of our Privacy Notice, email our Compliance Department.

Patient Rights & Responsibilities

For a copy of our Patient Rights and Responsibilities document, email our Quality Management Department or call them at 888-999-7713. You can also download the Patient Rights and Responsibilities.

Connecticut Criteria

To access clinical review criteria utilized for ConnectiCare Commercial Member requests in Connecticut, access ConnectiCare Medical Management Pharmacy Policies and ConnectiCare Medical Management Medical Policy.

To access clinical review criteria utilized for Emblem Commercial Member requests in Connecticut, access Emblem Health Medical Policies.

Kentucky Commercial Members

To access the utilization management procedures and commercial preauthorization list for Humana health plan, access 

Clinical Criteria for Health Utilization Management Decisions

Evolent applies nationally recognized clinical criteria and standards of care to medical necessity reviews. As available, CMS National and Local Coverage Determination Criteria and Medicare Guidance and CMS recognized Compendia are utilized for Medicare Advantage service requests. Health Plan specific clinical policies and nationally recognized oncology and cardiology consensus guidelines and compendia may also be applied for Medicare, Medicaid and Commercial member reviews.

Clinical criteria utilized to issue an authorization are available upon request by contacting the Evolent Health Utilization Department at:

915 W. Imperial Highway, Suite 200
Brea, CA 92821
888-999-7713, Option 1

Medical Policies

Please note that the following policies are posted for reference only. Based on the member’s benefit coverage, Evolent policies may be utilized for determinations. Health Plan policy or State mandated policy may be used before Evolent policy based on the Health Plan. Medicare determinations will follow the clinical criteria set forth by CMS using National Coverage Determinations (NCD), Local Coverage Determinations (LCD), CMS Guidance documents or the five Compendia approved by CMS for cancer drugs. The policy versions posted may not apply to all health plans. At any time, you may request the specific clinical criteria used in a determination decision.

Oncology  |  Radiation Oncology  |  Imaging  |  Cardiology

Please direct any questions to

Affirmative Statement

Evolent’s policy states that utilization review decisions are based only on medical necessity, appropriateness of care and service and the existence of coverage. There are no rewards, bonuses or incentives for practitioners or other individuals for issuing denials or approvals of coverage, service or care. There are no financial incentives for utilization management decision makers to encourage decisions that would result in underutilization or over-utilization. All medical necessity determinations are based upon nationally recognized standards of care and clinical guidelines and are not influenced by financial or in-kind incentives.