FLASH: New Process for New Therapy Preauthorization Requests through eviCore

For the first therapy request received during a patient’s episode of care, these are the minimum numbers of visits you can expect:

Pediatric Cases

• Will receive a minimum of 12 visits over 90 days

Post-Surgical Cases

• Will receive a minimum of 12 visits in 45 days

All Other Cases

• Will receive a minimum of 6 visits over 30 days

Providers should continue to send eviCore basic information, like member information and provider information, to create a case through Your Health Alliance for providers or on the phone.

eviCore will then ask a few questions to figure out if you’re seeking a pediatric, post-surgical, or other type of preauthorization. It will also ask 3 to 5 questions in the clinical portion of the case to determine if more visits are appropriate and to help streamline the process for future visits.

You aren’t required to submit any additional clinical information or any specific answers to any of these questions in order to receive the minimum number of approved visits above.

This process is for new requests only and works best for cases submitted online or on the phone. Cases started by fax will not be processed quickly.

There are no changes to the way eviCore will handle subsequent therapy requests at this time. Providers may receive additional visits immediately online or on the phone. They may still be required to submit clinical information for therapist review.

If you have any questions, contact your provider relations specialist.

Requesting Split-Night Sleep Studies

There have been a few questions about requesting split-night sleep studies, so we’ve put together the details for you to review:

1. When you start a preauthorization for a split-night study on eviCore through Your Health Alliance for providers, request CPT 95811.

2. While you’re building the case, eviCore will ask if this is a planned split-night study. Choose Yes.

3. Don’t be alarmed if you receive authorization for 95810 instead of 95811. If the case meets eviCore’s guidelines, approval will be granted for 95810 instead of 95811 because the member might not actually need a split-night study once the test begins.

4. If you end up performing only 95810, bill CPT 95810. If you end up performing the split-night, bill CPT 95811.

5. Our claim system will pay for the CPT code you’ve billed on the claim, regardless of the code that was approved on the eviCore preauthorization.

We hope this answers all of your questions. If you still have concerns, contact your provider relations specialist.