Outpatient Rehabilitation

  • New Process in 2022 for Specialized Therapy Requests
    Effective January 3, 2022, eviCore is updating its clinical collection process for specialized therapy requests. This will include clinical pathways for musculoskeletal and OT/PT pediatric neurodevelopmental conditions. This change requires less information, increases the opportunity for a real-time decision if criteria is met, and standardizes the clinical collection process for all health plans. Revised clinical worksheets will be available at eviCore.com.

  • Tips for requesting reviews through eviCore healthcare

    • Premera doesn’t require providers to request a medical necessity review through eviCore for the first 6 treatment visits of an episode of care (active treatment within a 90-day period) for outpatient rehabilitation services. After the patient's 6th visit, request a medical necessity review by calling eviCore healthcare at 800-792-8751, from 7 a.m. to 7 p.m., Monday through Friday, or visit eviCore healthcare.
      • An episode of care is defined as services provided by the same provider type within a 90-day period, based on the claim’s date of service.
      • When a Premera member receives treatment for the same episode of care by different provider specialties, each provider specialty receives 6 treatment visits.
      • When a Premera member sees multiple providers of the same provider type for the same episode of care, the first 6 treatment visits are combined between the multiple providers. Premera processes claims in order of receipt up to the 6 treatment visits. The 7th visit requires a medical necessity review.
    • The Physical and Occupational Therapy Services payment policy has specific unit limits for various services. These limits are enforced in the Claims Editor. Review the policy to avoid a claim edit.
    • Use our prior authorization tool to see if eviCore review is needed.
    • Include the member's plan prefix and number (i.e., “ABC123456789” - no spaces).
    • If the system says "no authorization required,” take a screenshot in case of retrospective review.

    Individual Plans

    Individual Plans use a separate code list, prior authorization tool, and online submission tool Identifi (not eviCore). Sign in to Individual Plan tools.

    Outpatient rehabilitation codes

    Check our code list to view outpatient rehabilitation codes. If no results are found, the code doesn't require review. We review non-specific codes when the claim is submitted.

    More information

    To create an account and/or initiate an authorization:

    • Visit eviCore healthcare
    • Call 800-792-8751 from 7 a.m. to 7 p.m., Monday through Friday (Out-of-network providers: submit requests by calling this number.)
    • Fax an eviCore healthcare request form to 800-540-2406
      (Go to Online Forms & Resources to select the specific treatment form.)

    Visit eviCore healthcare for:

    • Orientation, corePath training, tutorials
    • Clinical guidelines and worksheets
    • Frequently asked questions (FAQ)
    • CPT code list
    • Medical necessity review authorization request (available through the clinical certification online tool)
    • Performance summary reports (sign in and select PPS in top navigation)

    eviCore healthcare is an independent company managing outpatient rehabilitation services for Premera providers.