Physical Medicine
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Physical Medicine program

Obtain or verify an authorization

CPT codes

View codes that require authorization or notification on our pre-authorization lists.

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

Physical Medicine program

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 medicine and therapies (physical, occupational, speech and massage therapies; acupuncture and chiropractic/manipulation treatments)

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

  • Eligibility verification
  • Benefit interpretation
  • Appropriateness of service
  • Medical necessity determinations
  • 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.

Members included and excluded in the program

This program applies to members residing in Idaho, Oregon, Utah and Washington. We require authorization for codes as indicated on our pre-authorization lists. Some administrative services only (ASO) groups may also participate in this program.

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

Members 17 and younger

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. These diagnosis codes (PDF) do not require an authorization from eviCore for:

  • Acupuncture
  • Physical, occupational, speech and massage therapies
  • Chiropractic/manipulation treatments codes

ASO group information

Spinal surgery
Excluded ASO groups have pre-authorization requirements for spinal surgery that are noted on our pre-authorization lists.

If you contact eviCore to pre-authorize a spinal surgery and you receive the message below, please review our pre-authorization lists for spinal surgery codes that require pre-authorization.

  • No pre-authorization required at this time. Please note if this is for a spinal surgery, there may be additional pre-authorization requirements with your Health Plan. Please check the Health Plan's pre-authorization list on their provider website.

Physical Medicine
An ASO group may decide to purchase this benefit during their annual renewal period. The renewal period can vary by month, depending on the group. It is therefore important to check electronic authorization tool on the Availity Portal to determine if a patient's plan has changed.

Obtain or verify authorizations

Obtaining an authorization

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

  • eviCore's online tool
  • 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

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.

Verifying an authorization

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

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

Note: Once a notification or treatment request has been completed, the number may be referred to as the authorization number.

Spinal surgery

Spinal surgery

eviCore healthcare (eviCore) manages utilization of our inpatient and outpatient spinal surgeries. All spinal surgery codes indicated on our pre-authorization lists 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.

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

Post-service, prepayment claims review

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.

View the Spinal Surgery Frequently Asked Questions (PDF).

Pain and joint management

Pain and joint management

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:

  • 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.

Resources

Physical medicine and therapies

Physical medicine and therapies

All practice specialties billing therapy and manipulation CPT/HCPCS codes listed on our pre-authorization lists in the Physical Medicine program section (for physical, speech and occupational therapies; chiropractic; and complementary and alternative medicine) can submit a notification within seven days of the start of treatment in order to obtain a notification number. Submitting a notification may require minimal clinical information. Because you have seven days from the initial evaluation & management (E&M) appointment, you do not need to wait to schedule or treat the patient.

You are required to request a notification; the notification number authorizes payment for the initial evaluation and additional services provided on the date of the initial evaluation.

Please note: To ensure your claim is processed correctly, it is critical that you receive an approved notification from eviCore healthcare (eviCore) at least four days prior to submitting the claim.

The following services require notification:

  • Massage
  • Acupuncture
  • Physical, occupational and speech therapy
  • Manipulation treatments (not applicable for Medicare Advantage)

Note: Acupuncturists and massage therapists are not Medicare-eligible providers. Services rendered by these provider types are non-covered services for Medicare Advantage plans.

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

Program components

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 and chiropractic providers)
    • 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 ninety 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.

Members 17 and younger

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