3 common questions about Premera's Outpatient Rehabilitation Management program

outpatient rehab Wednesday, March 07, 2018

Outpatient rehabilitation (rehab) is part of every Premera health plan. It’s intended to help you recover from illness or injury. 

Over half a million Premera members seek care from a massage therapist, physical therapist, or occupational therapist each year. After prescriptions and office visits, rehab visits are the most common reason members use their health plan benefits.

Here are answers to some common questions about the Outpatient Rehabilitation Management program:

  1. Why does Premera require treatment plans for rehab care?

    In the past, many people used their rehab benefits until they ran out, even if they weren’t getting better. If they had another illness or injury, they would be out of visits and would end up paying out of their own pocket for care. Meanwhile, they were still dealing with the issue that sent them to rehab in the first place.

    Treatment plan reviews are an important check to make sure the care you’re getting is effective and medically necessary. This helps you:

    • Get the right care for your condition
    • Avoid paying for services that don’t help you recover
    • Have benefits available when you need them

    Treatment plans aren't required for the first six visits within 90 days after an injury or initial assessment if you live in Washington State or work for a Washington-based company.

  2. How does the review process work?

    When you visit your therapist the first time, they will assess your condition and treat you. After your first six visits, they'll need to send a treatment plan to Premera’s outpatient rehab review partner, eviCore. The treatment plan describes your care and tracks your progress to ensure you recover. It also helps ensure your provider is approved to treat you as part of your health plan coverage.

    eviCore uses medical best practices and clinical guidelines when reviewing treatment plans to determine the best duration and frequency of care, as well as medical necessity.

    Most treatment plans are reviewed within 24 hours.

  3. What if my treatment plan is denied?

    If your treatment plan is denied, your therapist can revise the plan and resubmit it for review.

    Your therapist can speak to a therapist at eviCore through a peer-to-peer process to make sure eviCore has all the necessary information.  

    You may appeal the decision. You and your therapist will receive a letter that details your appeal options.

If you have questions about this program, contact your referring doctor, therapist, or Premera customer service using the number on the back of your ID card.

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