Effective July 1, 2016, Premera will partner with eviCore healthcare to provide a review and authorization and process for outpatient rehabilitation services for our fully insured individual and group plans.
This new approach to outpatient rehabilitation services is designed to help members get the most from their coverage by ensuring treatments are right for their condition, effective, and medically necessary.
Premera selected eviCore healthcare because of its experience in overseeing physical medicine services. These recognized experts will partner with Premera to manage use of member benefits so that:
• Members reduce or eliminate ineffective use of their benefits
• Employers can expect costs for rehabilitation services to be managed wisely
Limiting unnecessary services helps control costs for everyone.
Types of services
Outpatient rehabilitation services included in this program are:
• Occupational therapy
• Physical therapy
• Massage therapy
• Rehabilitation services provided by chiropractors (this does not include spinal manipulations.)
The program will not be used to manage speech therapy, neurological occupational or physical therapy, and cardiac or oncology rehabilitation.
The new process
Here’s how the authorization and review process for outpatient rehabilitation services will work for dates of service July 1, 2016, and after:
• The member goes directly to the provider who can provide outpatient rehabilitation services (not the referring physician). The first visit, which includes an evaluation and possibly treatment, is covered based on benefit eligibility.
• The provider, after seeing the member, develops an outpatient rehabilitation treatment plan and sends the plan to eviCore for review.
• eviCore evaluates the treatment plan, determines medical necessity and notifies the provider and Premera of the number of authorized visits.
• Providers who send treatment plans using eviCore healthcare’s online portal will, in many cases, obtain a response to their request in real-time.
Communication to groups and members
The new process for outpatient rehabilitation services impacts all Washington, Alaska and Oregon insured individual and employer group plans, including Optiflex groups.
• Groups: Will be contacting insured groups starting early in May.
• Members: Premera will be reaching out to those who recently received treatment and those who had more than 50 visits in the past year. Members also will be notified by eviCore in writing if a request for services is not approved. This notice will include the member’s appeal rights and instructions to file an appeal.