Premera Blue Cross - Washington Implementation Resources

EviCore healthcare is working with Premera Blue Cross of Washington to provide medical necessity review for outpatient rehabilitation services.

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

• Physical Therapy
• Massage Therapy (excluding Microsoft)
• Occupational Therapy
• Premera Blue Cross (Washington Plans Only).

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.

Premera will allow an initial evaluation and management visit, and up to 6 subsequent visits without a treatment plan on file. Note: We reserve the right to do reviews for medical necessity for any medical services provided.

After the 6 consecutive visits, providers must submit a request for medical necessity review to EviCore healthcare for any on-going treatment.

Note: Members must be eligible and have available visits remaining in their benefit to be paid.

Note: For Premera Microsoft members the above applies for the first 12 treatment visits of an episode of care (active treatment within a 90-day period) for outpatient rehabilitation services.

For services found to be medically necessary, EviCore healthcare 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.

Treatment Requests Clinical Worksheets

EviCore healthcare accepts medical necessity review requests via web, telephone, or fax. Use the worksheets below to gather the clinical information required for a medical necessity review. Select the form that best fits the patient's condition. Be sure to complete every applicable section. Treatment Requests with incomplete sections may result in a request for missing clinical information that's needed to complete the review, causing a delay in the determination.

Claims Submission

After completion of the medical necessity request review process, EviCore healthcare 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 after the first six (6) treatment visits, the processing of that claim may stop and providers will be notified to request a medical necessity review from EviCore healthcare.

Note: In order for your claim to process without delay, after the 6 treatment visits, it's best that providers receive the approved medical necessity review prior to submitting the claim to the health plan for processing.