Outpatient Rehabilitation

  • Tips for requesting reviews through eviCore healthcare

    • For dates of service June 7, 2018, and after, Premera won’t require providers to request a medical necessity review through eviCore healthcare 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., weekdays, or visit the eviCore healthcare website created for Premera.
      • Premera defines an episode of care 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.
    • Reminder: The Physical and Occupational Therapy Services payment policy has specific unit limits for various modalities and services. These limits are enforced in the Claims Editor. To avoid a claim edit, please review the policy. Learn more in the July 19, 2018, Provider News article.
    • eviCore healthcare offers online training for CorePath. The training is available on the Premera page under Resources.
    • Member eligibility can change monthly. Check our prior authorization tool to see if a member needs eviCore healthcare review. The tool instructs you to use eviCore healthcare only when a service requires review.
    • When submitting a request for services, include the member's plan prefix and number (such as, “ABC123456789” - no space between the characters).
    • When you're checking a patient's eligibility and the system says "No authorization required,” you can take a screenshot for your records. We'll consider this if a retrospective review is required.
    • With some services for oncology, neurodevelopmental, or behavioral health, you might not need authorization. We encourage you to submit the authorization request, anyhow. If the specific services for this member are excluded from the program, we'll let you know that you don't have to take any further action.
    • You can check your performance compared to your peers. View your Practitioner Performance Summary reports at eviCore healthcare.

    Outpatient rehabilitation codes

    Check our code list to view outpatient rehabilitation codes. (Once in the list, use CTRL+F for PCs or Command+F for Macs, and type in the code. 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 for dates of service on or after July 1, 2016

    • Visit eviCore healthcare
    • Call 800-792-8751 from 7 a.m. to 7 p.m., weekdays. (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/training sessions
    • Quick reference guides
    • Clinical guidelines
    • Tutorials
    • Frequently asked questions (FAQ)
    • CPT code list
    • Medical necessity review authorization request (available through the clinical certification online tool)
    • Performance summary reports

    eviCore healthcare (formerly known as CareCore National) is an independent company managing outpatient rehabilitation services for Premera providers.