Physical, speech and occupational therapy - outpatient
eviCore healthcare has been contracted by Security Health Plan to provide prior authorization (PA) review of certain therapy services.
These authorizations will be for members enrolled in the following plan types: Security Health Plan employer, individual and family, BadgerCare, Medicare Advantage and Insite by Security Health Plan. For all Insite by Security Health Plan groups please review each member ID card to find the utilization management vendor (e.g. Hines) and prior authorization requirements.
Prior authorization for therapy is not required for FHC or members with Medicare or BadgerCare FFS prime.
It is the rendering provider’s responsibility to ensure prior authorization requirements are met before a member’s scheduled appointment. If PA requirements are not met, claims could be denied.
Rendering providers should contact eviCore to obtain prior authorization for members per the guidelines outlined above, and in the provider training materials.
Therapy and interventional pain management services performed in conjunction with an inpatient stay, 24-hour observation or emergency room visit are not subject to prior authorization requirements.
Authorization is required for:
- Occupational therapy
- Physical therapy
- Speech therapy
When requesting prior authorization (PA) from eviCore for outpatient therapies there are several types of limitations to review on the authorization letter such as:
- Visits approved
- Units approved
- Authorization date range
In the example above, Authorization is valid from Oct. 2, 2019 – April 1, 2020. There are 26 dates of service approved within this date range. There are 104 units approved to use within the 26 dates of service and date range. Some therapies are required to be billed in 15-minute increments. This means that if 45 minutes of therapy are billed on one date of service, one visit and three units of the authorization are used.
Request Authorization
To request prior authorization:
- Log in to www.evicore.com/pages/ProviderLogin.aspx
- Call eviCore at 1-888-444-6185
- Fax an eviCore healthcare request form (available at www.evicore.com) to 1-888-785-2485
For urgent requests:
If services are required in less than 48 hours due to the severity of the clinical presentation, please call eviCore’s toll-free number or you can initiate a case via the eviCore web portal for expedited prior authorization review. Be sure to tell the eviCore representative that the prior authorization request is for an urgent clinical presentation. If initiating the urgent request via the web you will have to upload clinical documentation with the case initiation. To request an authorization, submit your request online, by phone or fax.
Resources
View code list for the following prior authorizations:
General information
- Physical therapy and occupational therapy code list
- Authorization request overview for physical, occupational and speech therapy services
- Therapy program quick reference guide
- eviCore therapy program FAQs
- SMART Goals Overview
Speech therapy
- Speech therapy code list
- Clinical speech therapy QRG
- Speech therapy adult PA checklist
- Speech therapy pediatric PA checklist
- eviCore specialty therapy FAQs
Physical and Occupational therapy
- Clinical Physical and Occupational QRG
- Administrative Physical and Occupational QRG
- Initial request for pediatric care
- SMART Goals - Physical and Occupational Therapy
- eviCore specialty therapy FAQs
eviCore healthcare’s Clinical Guidelines and request forms are available at: www.evicore.com or access guidelines specific to Security Health Plan. Please call the Client Provider Operations Department at 1-800-646-0418, option 4, if you have any questions or need more information.