This program applies to migrated members only. Review other authorization requirements for non-migrated members.

Physical Medicine program for migrated members

Our Physical Medicine program is designed to meet our commitment to our members to ensure:

Members obtain the most from their healthcare coverage.
We are responsible stewards of the cost of healthcare.
Treatments are medically necessary and given at the right time and place.

EviCore by Evernorth (EviCore) administers the Physical Medicine program component of our overall utilization management program. Partnering with EviCore allows us to provide quality support to both providers and members.

Obtain or verify an authorization

Use EviCore's online tool ›

Phone 1-855-252-1115 or fax 1-855-774-1319, 7 a.m. to 7 p.m. CT Monday through Friday

CPT codes

View codes that require authorization or notification on our Commercial Migrated Member Prior Authorization List. Determine whether your patient's plan participates in this program by checking eligibility and coverage using Availity Essentials.

Our Physical Medicine program includes the following components:

Spine-related services
Joint management

EviCore provides full utilization management, including receiving and processing prior authorization requests for:

Eligibility verification
Benefit interpretation
Appropriateness of service
Medical necessity determinations for the service, or in the case of some joint surgeries, for the site of service
Post-service, pre-payment review for delegated services

Each participating physician or other healthcare professional who seeks payment authorization under this program must register using EviCore's website.

Members included and excluded in the program

Program participation varies by location and line of business. Codes that require prior authorization are published on our Commercial Migrated Member Prior Authorization List. Check whether your patient's plan participates in this program by using Availity Essentials.

Administrative services only group information

Administrative services only (ASO) groups that do not participate in our Physical Medicine program may still have prior authorization requirements for some of these services. View these requirements on our Commercial Migrated Member Prior Authorization List.

Joint management and spine

Some ASO groups may require authorization through BCBSND or EviCore, depending on whether the member’s plan participates in our Physical Medicine program.
To determine which program an ASO member participates in, use the Authorization request on Availity Essentials.

Additional information from EviCore

Obtaining an authorization

Authorizations and notifications can be submitted through:

EviCore's online tool or route from Availity Essentials via single sign on
Phone 1-855-252-1115 or by fax at 1-855-774-1319, 7 a.m. to 7 p.m. CT Monday through Friday

Treatment request clinical worksheets

Treatment request clinical worksheets facilitate case handling for all authorization and notification requests. Use the worksheets to gather clinical information required for web or telephone treatment requests. We strongly encourage all providers to submit notifications online.

Fax is available when submitting online isn't an option. When faxing treatment requests, select the form that best fits the patient's condition and be sure to complete every applicable section. Incomplete treatment requests may delay clinical review. Instructions for completing the request are included in the guide accompanying each condition-specific treatment request.

Verifying an authorization

To verify the status of an existing prior authorization or notification request:

Use EviCore's online tool or route from Availity Essentials via single sign on
Phone 1-855-252-1115 from 7 a.m. to 7 p.m. CT Monday through Friday

Notes:

Once a notification or treatment request has been completed, an authorization number is generated.
All requests’ statuses are accessible through the eviCore Portal, regardless of the platform they were submitted. Availity Essentials is an additional option for requests submitted through Availity Essentials.
- EviCore’s portal.
- Availity.

System outage workaround

EviCore offers three options for submitting authorizations or notifications:

Online: Use EviCore’s portal for the fastest submission option.
Phone: Call 1-855-252-1115
Fax: 1-855-774-1319

If one submission option is unavailable, use the next available option. If all submission options are unavailable, submit affected authorization requests within two days after systems are restored.

Retroactive authorization requests are accepted for dates affected by an outage. Retroactive requests are still subject to member eligibility and medical necessity review.

EviCore provides utilization management services for inpatient and outpatient spinal surgery benefits. Spinal surgery codes listed in the physical medicine section of the Commercial Migrated Member Prior Authorization List require prior authorization through EviCore for all members included in the program.

Note: ASO groups that do not participate in the Physical Medicine program may still be subject to spinal procedure and surgery prior authorization requirements as listed on our Commercial Migrated Member Prior Authorization List. Check the list to confirm whether requirements apply.

Failure to secure authorization approval for these services will result in claim non-payment and provider write-off.

Determine whether your patient's plan participates in this program by using Availity Essentials.

Post-service, prepayment claims review

All spine surgery procedure claims authorized through EviCore for providers and facilities may also be reviewed as part of a post-service, prepayment claims review. As part of this review:

EviCore may contact the provider or facility directly by fax to request documents that include, but are not limited to, operative notes, clinical medical records, itemized bills or invoices to process claims.
If you receive a request from EviCore, please submit the information within the required 45 days. Failure to submit the requested information within that time frame may result in a complete claim denial.

Our Physical Medicine program includes an authorization process for arthroscopy and joint replacement. Our goal is to partner with affected providers to help our members prepare for procedures, navigate the healthcare system and engage in their care.

Determine whether your patient's plan participates in this program by checking eligibility in Availity Essentials.

Please note the following:

All arthroscopy and joint replacement CPT/HCPCS codes indicated on our Commercial Migrated Member Prior Authorization List in the physical medicine section for joint management require prior authorization through EviCore for all members who participate in the program.
Failure to secure authorization approval for these services through EviCore will result in claim non-payment and provider write-off.

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policy Search

Physical Medicine program for migrated members

Obtain or verify an authorization

CPT codes

Additional information from EviCore