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HighmarkCommercial · Prior Auth · Provider Bulletin · NY, DE, PA, WV · Oncology, Radiation OncologyHigh impact

Evolent to Manage Medical and Radiation Oncology Authorizations

Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 24, 2026

Summary

Beginning January 1, 2027, Evolent will manage prior authorization reviews for medical and radiation oncology services for Highmark Commercial members in New York and ASO members in Delaware, New York, Pennsylvania, and West Virginia. Prior auth for oncology services WITH a cancer diagnosis will be managed by Evolent, while services WITHOUT a cancer diagnosis will remain with Highmark's UM team. Initial auth requests still submit through Availity, but supporting clinical documentation for Evolent reviews must be uploaded to Evolent's CarePro portal.

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What to do

by Dec 31, 2026 · 5 steps
01Billing team must update internal workflows and staff training to route oncology prior authorization requests based on cancer diagnosis status—Evolent for cancer diagnoses, Highmark UM for non-cancer diagnoses.
02Providers and billing staff must register for and gain access to Evolent's CarePro portal at evolent.com/provider-portal to upload supporting clinical documentation for cases requiring Evolent review.
03Update authorization submission procedures to clarify that initial requests continue through Availity Essentials, but clinical documentation for Evolent-managed cases must be uploaded to CarePro portal separately.
04Establish documentation requirements checklist for oncology cases to ensure medical necessity support is available for Evolent review.
05Verify that billing system can differentiate between cancer and non-cancer diagnoses to properly route auth requests.
If missed: Failure to route requests correctly will result in claim denials or authorization delays.

Original notice

Evolent to Manage Medical and Radiation Oncology Authorizations
providers.highmark.com · Always check the source before changing claims.
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Related changes

See all Highmark changes →
Evolent Transition: Sign Up for Oncology Prior Auth TrainingHighEffective May 1, 2026 · Prior AuthorizationReminder: Register For Evolent Oncology Prior Authorization TrainingHighEffective May 1, 2026 · Provider BulletinBrowse every Highmark change in the policy list

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Highmark policiesNY policy changesDE policy changesPA policy changesWV policy changesOncologyRadiation Oncology

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