Premera Blue Cross Provider Resources

EviCore by Evernorth partners with Premera to provide medical necessity review for outpatient rehabilitation services.

A medical necessity review may be required for the following services:

• Physical Therapy
• Massage Therapy
• Occupational Therapy

For services found to be medically necessary, EviCore will provide a notification number and date range. Services that aren't medically necessary will be denied. Claims submitted without a medical necessity review may be pended until one is received.

Services performed in conjunction with an inpatient stay, 23-hour observation, or emergency room visit aren't subject to medical necessity review. Patients under the age of 8 are also not subject to these requirements.

Claims Submission

After completion of the medical necessity request review process, EviCore will send the medical necessity determination to the Health Plan. The medical necessity determination will be used to process claims. If the health plan receives a claim without a corresponding medical necessity review, the processing of that claim may stop and providers will be notified to request a medical necessity review from EviCore.