Outpatient Rehabilitation Management Program

  • Premera’s outpatient rehabilitation management program reviews treatment plans for physical therapy, occupational therapy, massage therapy, and some chiropractic services (except spinal manipulations).

    All fully insured and OptiFlex medical plans include this program. It is available as an optional service for self-funded groups.

    What is outpatient rehabilitation?

    • Outpatient rehab is intended to help your employees recover efficiently from illness or injury.
    • The care happens outside of a hospital, and may include massage therapy, physical therapy, or occupational therapy.
    • Outpatient rehab benefits are part of every Premera health plan.

    What is a treatment plan?

    If you're employee needs outpatient rehab, their therapist will assess their condition and provide treatment during their first visit.

    Their therapist writes a treatment plan that includes info about their condition, progress, and treatment goals. This plan shows the member, their referring doctor, and Premera how the therapist plans to help them heal.

    Why does Premera require treatment plan reviews for rehab care?

    Reviewing a member's treatment plan is an important way to make sure they’re getting effective and medically necessary care. This helps the member:

    • Get the right care for their condition
    • Avoid paying for services that don't help with recovery
    • Have benefits available when they're needed

    Who reviews the treatment plans?

    • Reviews are conducted by eviCore, a national leader in managing medical benefits that's accredited by the Utilization Review Accreditation Commission and the National Committee for Quality Assurance.
    • eviCore serves over 100 million patients in the U.S. They rely on 25 years of experience to help patients receive the most appropriate medical care based on their unique clinical situation.
    • Reviewers are doctors and therapists in the field of care you need. For example, if you need physical therapy your treatment plan will be reviewed by a physical therapist.

    How does the review process work?

    1. Your employee sees their therapist, who assesses and treats their condition during the first visit.
    2. Their therapist writes a treatment plan about their condition, progress, and treatment goals, and submits it to eviCore for review.
    3. eviCore’s medical professionals review the plan using medical best practices and clinical guidelines to determine the medical necessity, and best duration of care.
    4. Once the treatment plan is approved, your employee can proceed with their next visit.

    Most plans are reviewed within 24 hours.

    What if a treatment plan is denied?

    If your treatment plan is denied, your employee and their therapist will both be notified by letter. Your employee has several options:

    • Their therapist can revise and resubmit the plan
    • Their therapist can review the plan with an eviCore therapist or medical director
    • They may appeal the decision (details will be in the denial letter)

    How many visits do my employees have, what if they need more?

    Typically, eviCore authorizes 4 or 6 initial visits. If the therapist determines that more treatment is needed, they will submit a treatment plan to eviCore for additional visits.

    Do doctors and therapist know what to do?

    Doctors and therapists in Premera’s provider networks are familiar with this review process. If there is concern they may be unaware, your employees can share this information with them:

    • Outpatient rehab management is part of their health plan
    • A treatment plan should be submitted to eviCore, Premera’s outpatient rehab review partner
    • A revised treatment plan can be submitted at evicore.com
    • A peer-to-peer review with an eviCore medical director or therapist can be requested at evicore.com

    Who can my employees go to with questions?

    • Call Premera customer service at 800-722-1471, Monday through Friday, 5 a.m. to 8 p.m. Pacific time.
    • Send Premera customer service a message from their secure member inbox on premera.com.