For Blue Cross PPO (commercial) members
(for dates of service on or after Jan. 1, 2018)

Providers must obtain authorization from eviCore healthcare for:

• Outpatient interventional pain management
• Inpatient and outpatient lumbar spinal fusion surgery
• Outpatient radiation therapy (oncology)

Refer to the resources below for more information:

• Procedures that require authorization by eviCore healthcare (PDF) – List of procedure codes eviCore reviews
• Guidelines for services reviewed by eviCore healthcare for Medicare Plus Blue^SM PPO and Blue Care Network (PDF) – How to handle different types of authorization requests

For Medicare Plus Blue^SM PPO members

Providers must obtain authorization from eviCore healthcare for:

• Outpatient interventional pain management
• Inpatient and outpatient lumbar spinal fusion surgery
• Outpatient radiation therapy (oncology)
• Outpatient physical and occupational therapy services
• Inpatient post-acute care services (for members admitted through May 31, 2019)

For members admitted on or after June 1, 2019, submit post-acute care authorization requests to naviHealth. See the frequently asked questions document (PDF) for more information on this change.

Refer to the resources below for more information:

• Procedures that require authorization by eviCore healthcare (PDF) – List of procedure codes eviCore reviews
• Guidelines for services reviewed by eviCore healthcare for Medicare Plus Blue^SM PPO and Blue Care Network (PDF) – How to handle different types of authorization requests
• Sample PT-OT authorization form for Medicare Plus Blue^SM PPO (PDF) – Identifies mandatory fields and provides explanation of some field contents for the forms
• FAQ about eviCore physical therapy (PDF) – Answers common questions about the eviCore physical therapy program
• Tips for improving treatment efficiency, for members undergoing physical therapy (PDF)
• corePath^SM model of therapy authorization (PDF) – Introduces the new, streamlined authorization process for physical and occupational therapy visits
• FAQ about corePath^SM model of therapy authorization (PDF) – Questions and answers from corePath model of therapy authorization training sessions
• Musculoskeletal Specialized Therapy Program* (PDF) – Questions and answers about PT practitioner performance summary and provider categories

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For related information on:

• Care management requirements for various services, refer to the Provider Toolkit page at bcbsm.com. Look under the "Care management" heading.
• Authorization requirements for other procedures, refer to the Authorization Requirements & Criteria page in the Blue Cross section of this website
• Drugs covered under the medical benefit, visit the Medical Benefit Drugs – Pharmacy page in the Blue Cross section of this website

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