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.
View a list of members who participate in the program (PDF).
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:
- Physical, occupational, speech and massage therapies
- Chiropractic/manipulation treatments codes
ASO group information
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.
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 on a monthly basis to determine if our ASO group list (PDF) has changed because of an ASO group purchasing the program.