All practice specialties billing therapy and manipulation CPT/HCPCS codes listed on our Commercial Pre-authorization List and Medicare Advantage Pre-authorization List 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.

View members who are included and excluded from this program.

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.