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Provider Manual

Musculoskeletal (Joint Surgery, Spine Surgery, Interventional Pain Management) and Therapies (Occupational Therapy, Physical Therapy, Speech Therapy)

Last Updated on May 14, 2019

eviCore healthcare has been contracted by Security Health Plan to provide prior authorization (PA) review of certain musculoskeletal and therapy services for dates of service (DOS) May 1, 2019 and forward.

These authorizations will be for members enrolled in Security Health Plan Commercial, BadgerCare, and Medicare Advantage plans and the Security Administrative Services (SAS) plan for the Marshfield Clinic Health System Employer group.  For all other SAS groups please review each member ID card to find the utilization management vendor (e.g. Hines) and prior authorization requirements.

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.

Marshfield Clinic rendering providers should contact Security Health Plan to obtain PA for members. 

Non-Marshfield Clinic rendering providers should contact eviCore to obtain PA for members, per the guidelines outlined above and in the provider training materials.

An expansion of the eviCore programs to include Cardiac imaging and Sleep Study programs, will become effective July 1, 2019.  eviCore will not be managing any durable medical equipment (DME) such as: pap, pap supplies and oral appliance. The current DME prior authorization will not change. Watch for forthcoming information on the Security Health Plan website. https://www.securityhealth.org/providers

Therapy and interventional pain management services performed in conjunction with an inpatient stay, 23-hour observation or emergency room visit are not subject to prior authorization requirements.

Authorization is required for:

  • Joint Surgeries
  • Spine Surgeries
  • Interventional Pain Management
  • Occupation Therapy
  • Physical Therapy
  • Speech Therapy

Request Authorization

To request a prior authorization:

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:

Authorization request overview for physical, occupational and speech therapy services
Therapy program quick reference guide
eviCore therapy program FAQ

Musculoskeletal management provider orientation session
Musculoskeletal   management quick reference guide
eviCore  musculoskeletal program FAQ

eviCore healthcare’s Clinical Guidelines and request forms are available at: www.evicore.com.    Please call the Client Provider Operations department at 1-800-646-0418, option 4, if you have any questions or need more information.