Here’s updated information about MA PPO Physical Therapy Use Management Program

Blue Cross Blue Shield of Michigan continues to partner with eviCore for its Medicare Advantage PPO Physical and Occupational Therapy Program. In response to questions we’ve received from health care providers, we’d like to provide updated information about the program.

Thanks to all of you who notified us about issues you’ve experienced during the first quarter of the program. Your input helps us make improvements to the program, which will be especially beneficial as we move forward with preauthorization for our commercial product in 2018.

Preauthorization

• All cases are reviewed on an individual basis for medical necessity so the number of approved visits may vary.
• Providers may request additional visits for approval within the original 30-day period; additional visits will also be based on medical necessity.
• If you don’t use all the approved days for an original issue and want to begin therapy on a second issue, use the days that have already been approved. Notify eviCore of the new therapy if additional days are required for the secondary issue after the approved days have been exhausted.
• If treatment begins on the same day of the evaluation, you must have the treatment approved. The start date is always the first day treatment begins.
• Initial evaluations don’t require preauthorization. We’re making the appropriate edits to our system to accommodate this.
• Reevaluations for PT and OT do require authorization.
• Peer-to-peer reviews may be requested before a denial is made. This allows the provider to have full understanding of the medically necessary information eviCore is looking for to approve services.
• Once a denial is made by eviCore, eviCore can’t overturn it. The case must be appealed through Blue Cross.
• Providers may upload or fax specific information to eviCore if they’re unable to add it on the form that’s been posted on the portal. Doing this may result in a longer response time from eviCore.
• If additional visits are required, the provider may go back to eviCore seven days before the end of the approved period. Approval will be based on the most current documentation of medical necessity.
• Providers can log in to the portal to see the status of their request. Simply select auth lookup and it will display the approval date, expiration date, number of visits approved and number of units approved.
• All Centers for Medicare & Medicaid Services documentation requirements for reporting remain the same. However, it’s no longer necessary to report the level of functional improvement that a Medicare Advantage patient has achieved.

Provider categories

• Blue Cross will categorize providers in January and July. Providers should be receiving their categorization letters in early to mid-February and early to mid-August. The effective dates for the new categories will be April and October, depending on when the categorization occurred.
• Providers can check the portal for their current categorization information.

Upcoming upgrades

• eviCore and Blue Cross are working together to provide a job aid to assist our providers with identifying mandatory versus optional fields on the web portal. In addition, eviCore is working on ways to update the portal to expedite the authorization process.
• eviCore is working on new pathways that will expedite the overall authorization process and eliminate the redundancy of information requested after the original case has been entered.
• Blue Cross will set up training sessions when the upgrades have been completed.