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Premera Pre-Authorization Update #3

Wednesday, June 29, 2016   (8 Comments)
Posted by: Sheri Ryan
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ACS Member Update #3 
Wednesday 29 June 2016

Did you Know?  Select modality/therapy CPT codes provided in chiropractic offices will now fall under the NEW Pre-authorization program for Outpatient Rehabilitation Services for some Premera Plans effective 7/1/2016 through eviCore Healthcare.    Are you ready?  ACS has a plan...

ACS is getting reports from chiropractic offices who attended the eviCore implementation webinars the past couple of days.  There was confusion during the webinar on eviCore's part as to whether chiropractic offices were subject to the new outpatient rehabilitation services pre-authorization program implemented by Premera Blue Cross Blue Shield of Alaska.  Well folks, I'm sorry to tell you, but it does affect chiropractic offices who bill these modality/therapy select CPT codes under effected Premera plans.  I talked with the Regional Provider Engagement Manager for eviCore this morning.  Their confusion with regards to chiropractic services was because they do utilization review in the lower 48 for CMT codes.  DCs on the webinar were questioning if the new program effected chiropractic services.  The new Premera pre-authorization program effective 7/1/2016 does NOT affect CMT codes (98940 - 98942), diagnostic imaging codes, E/M codes or other services in a DC office - IT ONLY AFFECTS the select CPT codes for modalities and therapeutic procedures in this list CLICK HERE!  If your chiropractic office bills for such things like 97010 (hot/cold packs), 97012 (traction), 97014 (electric stim), 97035 (ultrasound), 97110 (therapeutic exercises), 97124 (massage), 97140 (manual therapy), - just to name a few - you need to sign up with eviCore and are required effective 7/1/2016 to get pre-authorization for ONGOING TREATMENT plans for affected Premera plan Members.  Pre-authorization for these affected codes are not required on an initial visit - only ongoing treatment.  

Some Premera Plans excluded from pre-authorization program are FEP (Federal), Medicare Supplemental; Medicare Advantage, and Blue Card Host.  Self-funded Premera plans have the option to opt-in to the pre-authorization program.  Use eviCore website Eligibility Lookup Tool to determine which plans are affected.   Pre-auth is also not required for secondary insurance plans.  

Starting June 17, you can 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 am to 7 pm local time Monday through Friday
  • Fax an eviCore healthcare request form (available online) to 855-774-1319

Visit eviCore healthcare's website where you'll find the following helpful information and more:

  • FAQ - This has some REALLY VALUABLE INFO - CHECK IT OUT!  Here's a few highlighted items:  Medical necessity authorizations are typically approved for a 30-day period.  However, periods may be shorter or longer depending on the member's conditions and timing of the request.  If medical necessity can be established based on evidence-based criteria, visits will be authorized at the time of your treatment request submission.  When you submit online, this authorization will be instantaneous.  Requests requiring clinical evaluation will be reviewed by appropriate specialty clinicians...

  • Webinar Trainings provided by eviCore - June 29, June 30, + July 7.  They will discuss in detail the prior authorization requirements for Premera members and how to locate additional training materials to navigate the eviCore Web site.  Topics to be discussed include the new prior authorization process, accessing information from the Website and a review of the Quick Reference Guides.  Time and participation permitting, this orientation session will be followed by a question and answer session.  You are encouraged to attend one of these informative sessions to ensure your understanding of the NEW prior authorization process for these select MSK Services.  NOTE:  PRE-AUTH DOES NOT CONTAIN CMT codes - ONLY SELECT THERAPY CODES
  • Quick Reference Guides
  • Clinical Guidelines for Chiropractic Services - this link is provided so you can get a feel for how eviCore's determination of medical necessity and the therapies associated with certain chiropractic conditions.  Remember - Premera has only contracted with eviCore to do pre-authorization on a select list of CPT Codes that fall under Outpatient Rehabilitation Services.  Any other restrictions listed in this guideline (X-ray, E/M, CMT, etc.) DO NOT APPLY!  
  • Clinical Guidelines for Massage Therapy 
  • Massage Therapy Treatment Request Clinical Worksheet - use for 97124 and 97140
  • PT/OT Treatment Request Clinical Worksheet - use for all other therapies (97010, 97012, 97014, 97026, 97028, 97035, 97110, 97112, etc.)
  • Tutorial for Online Submission Process for MSK
  • Provider Orientation
  • Set up a Provider Account with eviCore
  • Provider Web Portal Quick Access Guide
  • CPT Code List - this NEW pre-authorization ONLY APPLIES TO THESE CODES!!
  • Medical Necessity Review Authorization Request (available through the Clinical Certification online tool)


Here's some helpful info that has come in from ACS Member offices... 


Therapies will be under a MSMPT request. Massage will be under a MSMMT request.


This is only for local Premera Blue Cross plans and does not include out of state or Federal plans. Self-funded plans may or may not be included (it is their choice) and this can be checked when doing a benefits verification. Be aware: the status of a self-funded plans inclusion could change at any time.


Treatment can be done on the initial visit and will be covered no matter what if it is billed with an exam. For patient's in the middle of treatment as of July 1st, send the original treatment plan and all current notes following that plan for approval.

Manage your deposits from the comfort of your own office with Chiropractic Remote Deposit.  There are no fees and CFCU provides you with the equipment you need. Deposits made by 2 pm (EST) receive same-day credit, and deposits after 2 pm can be viewed in your account the next day.  When you need support a Help Desk is available 8 am - 7 pm for scanner and software issues, or your CFCU staff is standing by to assist you.  Chiropractic Remote Deposit is a GREAT solution for your business.  To get started, call CFCU at 248.478.4020.


Sheri Ryan says...
Posted Thursday, July 21, 2016
From an ACS Member office -- Of course there are bugs with the recent roll out, but our biggest issue has been using the benefit tab and having it say that pre-auth is required for a patient, then going to the clinical tab to request the pre-auth and having it say the patient cannot be found. We have also had the system grant us a pre-auth on a patient whose employer is self insured and their company opted out of the pre-auth program (so no authorization was really needed). Didn't find this one out until one of our patients who works in HR called their director and confirmed that they had the choice to opt out. Lastly, when we called on these issues, we were told that the eligibility tool has incorrect info. and we shouldn't bother using it! The fact that is process takes up more staff time with no reimbursement makes our docs unhappy and we haven't even made it to round 2 yet (which would be asking for the next set of visits). Crossing fingers!!
Sheri Ryan says...
Posted Friday, July 15, 2016
From an ACS Member office ---- I have also discovered that University of AK, Alaska Airlines, and Lynden Transport groups opted out of the Auth program, and the labor unions AK Carpenters and Operating Engineers do not require authorizations either. If you know of other groups that opted out, please share that info.
Sheri Ryan says...
Posted Friday, July 15, 2016
From an ACS Member office ----- I contacted Blue Cross yesterday (07/14/2016) to get clarification on their definition of an “initial encounter”. I found out that Blue Cross was not expecting us to do anything other than an exam on the initial encounter. I guess we’re supposed to do the exam and send the patient away to come back another day for treatment. As we all know, that is not the real world! I believe the PT or MT at the initial encounter will be covered as long as the Authorization is done with Evicore with that first day being the beginning treatment date. To date, I’ve had no authorization requests denied, although I’ve not been paid on any July Blue Cross visits, either, so I guess we’ll see.
Sheri Ryan says...
Posted Thursday, June 30, 2016
Question - Do we need authorization for out of area blue cross blue shield? Answer - Please check with that patients plan. This program applies to Premera Blue Cross and LifeWise of Washington, Premera Blue Cross Blue Shield of Alaska and LifeWise of Oregon.
Sheri Ryan says...
Posted Thursday, June 30, 2016
Question - When checking if authorization is needed for a PBC plan will we check on the PBC website or Evicore website? Answer - You can check the healthplan website for eligibility or the eviCore portal. If you cannot find the member on the eviCore portal please confirm with the healthplan for eligibility.
Sheri Ryan says...
Posted Thursday, June 30, 2016
Question - I was wondering if the waiver period starts over at the beginning of each year? Answer - The waiver will be applied when there is a new condition or when there is at least a 90 day break in care. It is not an annual waiver. The provider may be able to get a waiver up to 2 times per year.
Sheri Ryan says...
Posted Thursday, June 30, 2016
Question - Do Chiropractic practitioners need to obtain authorization for PT codes being covered under this program. Answer - Yes, any specialty performing services listed under the auth code list located on the implementation site will need authorization.
Sheri Ryan says...
Posted Thursday, June 30, 2016
Question - If Premera is secondary is authorization required? Answer - No auth needed for secondary

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