eviCore healthcare to review epidural and facet joint procedures for BCN effective September 1

What's changing. Effective with dates of service on or after Sept. 1, 2016, eviCore healthcare will complete clinical reviews for non-emergent pain management services for facet joint and epidural injections. BCN Care Management has reviewed these procedures since April 2011 but with this change, eviCore will manage those services for BCN.

Currently, eviCore reviews certain outpatient radiology, cardiology and radiation therapy services for BCN. Separately, eviCore also reviews physical, occupational, and speech therapy, and physical medicine services provided by chiropractors.

For epidural and facet joint procedures, clinical review will be required for all diagnoses, for both BCN HMOSM (commercial) and BCN AdvantageSM members. This applies to services associated with the following procedure codes: *62281, *62282, *62310, *62311, *62318, *62319, *64479, *64480, *64483, *64484, *64490, *64491, *64492, *64493, *64494, *64495.

How to submit review requests. Starting September 1, providers will be able to submit requests for clinical review for these procedures in one of two ways:

Starting August 25, providers can call eviCore at 1-855-774-1317 to review requests for services that will begin on or after September 1.

All requests must be reviewed prior to the services being rendered. If a treating physician does not receive a medical necessity determination and authorization number from eviCore prior to performing procedures for which eviCore's review is required, claims may not be reimbursed.

Other information. eviCore's interventional pain guidelines will be made available to providers at evicore.com.

In addition, by the end of August, the document Procedures that require clinical review by eviCore healthcare will be updated to include the pain management procedure codes. This document is available on the eviCore-Managed Procedures page on this website.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: July 2016
Line of business: Blue Care Network