Our Physical Medicine program is designed to meet our commitment to our members to ensure:

• They obtain the most from their health care coverage
• We are being responsible stewards of the cost of health care

• Treatments they receive are medically necessary and are at the right time and place to improve their quality of life.

Our utilization management (UM) program requires compliance with the Physical Medicine program. eviCore healthcare (eviCore) administers the Physical Medicine program component of our overall UM program. Partnering with eviCore allows us to provide quality support to both providers and members.

Our Physical Medicine program includes the following components:

• Spinal surgeries
• Pain and joint management

• Physical, occupational and speech therapies

eviCore provides full utilization management, including receiving/processing pre-authorization requests for:

• Eligibility verification
• Benefit interpretation
• Appropriateness of service
• Medical necessity determinations for the service, or in the case of some joint surgeries, for the site of service

• Post-service, pre-payment review for spinal surgeries

Each participating physician or other health care professional who will be seeking payment authorization under this program is required to register using eviCore's website.

This program applies to all members residing in Idaho, Oregon, Utah and Washington.

Those excluded from this program include:

• Medigap members in Utah
• Any member where we are in the secondary health plan coverage position
• Out-of-network providers for exclusive provider organization (EPO) members (Note: Members on EPO products in Utah do not have out-of-network benefits. Services rendered by out-of-network providers are non-covered services.)

• Members receiving care outside our four State service area (Note: Out-of-state providers can choose to contact eviCore to receive authorization prior to performing the service. As this authorization is not a requirement, if not obtained, the claim will be reviewed for medical necessity once received.)

Select pediatric diagnosis codes are excluded from the physical medicine and therapies component of the program for enrolled dependents 17 and younger. Services are still subject to benefit limitations. Physical, occupational and speech therapies do not require authorization for members with these diagnosis codes (PDF).

Authorizations and notifications can be made by the servicing physician or other health care professional through:

• eviCore's online tool or choose to be routed from Availity’s electronic authorization tool via single sign on

• Phone 1 (855) 252-1115 or by fax at 1 (855) 774-1319, 7 a.m. through 7 p.m. Monday through Friday

View our Authorizations Quick Reference Guide (PDF) for some quick steps on how to initiate an authorization.

Treatment request clinical worksheets facilitate case handling for all authorization and notification requests. Use the worksheets to gather clinical information required for web or telephone treatment requests. We strongly encourage all providers to submit notifications online.

There is a faxing option when submitting online isn't an option. When faxing treatment requests, select the form that best fits the patient's condition and be sure to complete every applicable section. Incomplete treatment requests may delay clinical review. Instructions for completing the request are included in the guide accompanying each condition-specific treatment request.

To verify the status of an existing pre-authorization or notification request:

• eviCore's online tool or choose to be routed from Availity's electronic authorization tool via single sign on

• Phone 1 (855) 252-1115 or by fax at 1 (855) 774-1319, 7 a.m. through 7 p.m. Monday through Friday

Notes:

• Once a notification or treatment request has been completed, the number may be referred to as the authorization number.
• Check the status of your requests using the same platform you used to submit the request:
  • Requests submitted through eviCore are updated on eviCore’s portal: evicore.com.
  • Requests submitted through Availity Essentials are updated in Availity: availity.com.

eviCore healthcare (eviCore) manages utilization of our inpatient and outpatient spinal surgeries. All spinal surgery codes indicated on our pre-authorization list in the Physical Medicine section for Spine require pre-authorization through eviCore for all members listed as included in the program.

Note: Spinal procedure/surgery pre-authorization requirements as noted on our pre-authorization lists remain in effect as published for administrative services only (ASO) groups listed as they are excluded from this program.

Failure to secure authorization approval for these services will result in claim non-payment and provider write-off.

All spine surgery procedure claims authorized through eviCore from providers and facilities are reviewed as part of a post-service, prepayment claims review. As part of this claims review:

• eviCore may contact the provider or facility directly by fax to request documents that include, but are not limited to, operative notes, clinical medical records, and/or itemized bills/invoices to process claims.
• If you receive a request from eviCore, please submit the information within the required 45 days indicated in the request. Failure to submit the requested information within that time frame may result in a complete claim denial.

Our Physical Medicine program includes an authorization process for interventional pain management, arthroscopy and joint replacement. Our goal is to partner with impacted providers to help our members prepare for procedures, navigate the health care system and engage in their care.

Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

Please note the following:

• Some joint surgeries will require site of service review effective May 1, 2023.
• All pain management, arthroscopy and joint replacement CPT/HCPCS codes indicated on our pre-authorization lists in the Physical Medicine section for pain management or joint management require pre-authorization through eviCore healthcare (eviCore) for all members who participate in the program.

• Failure to secure authorization approval for these services through eviCore will result in claim non-payment and provider write-off.

• Pre-authorize a service with eviCore healthcare
• View eviCore healthcare's Joint and Pain Management Program webinar (PDF)

The initial evaluation and treatment visit does not require pre-authorization. If additional treatment is medically necessary, eviCore requires that a pre-authorization request be submitted within seven days of the initial visit.

The above applies to all practice specialties billing therapy and manipulation CPT/HCPCS codes listed on our pre-authorization list in the Physical Medicine program section.

Please review our complete pre-authorization list for details or use the Electronic Authorization application on Availity Essentials.

The Physical Medicine program services include:

• Physical therapy
• Occupational therapy

• Speech therapy

Notes:

• All program components must be followed. Terms and conditions related to our pre-authorization requirements apply.
• Submitting an authorization request may require minimal clinical information.
• To ensure your claim is processed correctly, it is critical that you receive an approved pre-authorization from eviCore healthcare (eviCore) at least four days prior to submitting the claim.
• Submitting an authorization request may require minimal clinical information.
• The pre-authorization number you receive from eviCore authorizes payment for the additional treatment services provided.
• If the servicing provider fails to obtain pre-authorization for additional treatment services provided, it will result in claims non-payment and will become a provider write-off.

• There may be other pre-authorization requirements through BridgeSpan for spinal surgery, pain or joint management. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials. You can also obtain benefits and eligibility information.

Pre-authorization is not required for an initial evaluation and management visit and up to six consecutive treatment visits in a new episode of care. After the patient’s sixth treatment visit an authorization is required.

We define a "new episode of care" as treatment for a new condition or diagnosis for which the patient has not been treated by a provider within the same Tax ID number and specialty within the previous 90 days and is not undergoing any active treatment for that condition or diagnosis. Anything beyond a new episode of care requires an authorization. When a member receives treatment for the same episode of care by different provider specialties, each provider specialty receives six treatment visits without requiring pre-authorization. View our FAQ for more clarification on an episode of care.

The Physical Medicine program services include:

• Physical therapy
• Occupational therapy

• Speech therapy

This mandate applies to members on our Washington plans.

Select pediatric diagnosis codes are excluded from the therapies component of the program (PDF) for enrolled dependents 17 and younger.

The Practitioner Performance Summary (PPS) is available to providers through the portal. The PPS uses claims data and allows providers to monitor changes in their practice patterns and compare their performance metrics to peer providers in the network.

• Initial authorization request (notification)
  • Eligible for a six-visit episode of care (for all physical therapy)
  • Physical therapy providers will be eligible for additional visits in the episode of care when the member presents with a qualifying condition (e.g., post-operative)
• Subsequent request for a new episode (A "new episode of care" means treatment for a new or recurrent condition for which the patient has not been treated by the provider group within the previous 90 days and is not currently undergoing any active treatment.)
  • Eligible for a new six-visit episode of care
  • Physical therapy providers will be eligible for additional visits in the episode of care when the member presents with a qualifying condition (e.g., post-operative)

• Subsequent request for an existing episode

  • Clinical information submission for medical necessity review will be required

We are also allowing providers to voluntarily submit additional outcome data on their authorization requests. The collected outcome measures will eventually be added to the PPS dashboard.

Notes:

• All program components must be followed. Terms and conditions related to our pre-authorization and notification requirements apply.
• If the servicing provider fails to obtain authorization or notification for required services by the servicing provider, this will result in claim non-payment and will become a provider write-off.