Outpatient Rehabilitation

  • New Process in 2022 for Specialized Therapy Requests
    Effective January 3, 2022, eviCore is updating its clinical collection process for specialized therapy requests. This will include clinical pathways for musculoskeletal and OT/PT pediatric neurodevelopmental conditions. This change requires less information, increases the opportunity for a real-time decision if criteria is met, and standardizes the clinical collection process for all health plans. Revised clinical worksheets will be available at eviCore.com.

    For GAIP members: request reviews from LifeWise

    • GAIP is the Graduate Appointee Insurance Program.
    • After 12 visits, providers submit a review request to our care management team to ensure additional sessions are medically necessary.
    • For GAIP members, no eviCore review is required.

    For ISHIP members: request reviews through eviCore healthcare

    • ISHIP is the University of Washington International Student Health Insurance Plan, for Seattle, Bothell, and Tacoma campuses.
    • LifeWise doesn't require providers to request a medical necessity review through eviCore healthcare for the first 6 treatment visits of an episode of care (active treatment within a 90-day period) for outpatient rehabilitation services. After the patient’s sixth visit, request a medical necessity review by calling eviCore healthcare at 800-792-8751, from 7 a.m. to 7 p.m., weekdays, or visit the eviCore website created for LifeWise.
    • The Physical and Occupational Therapy Services payment policy has specific unit limits for various modalities and services. These limits are enforced in the Claims Editor. To avoid a claim edit, please review the payment policy.
    • Use our prior authorization tool in Availity to see if a member needs eviCore healthcare review. The tool instructs you to use eviCore healthcare only when a service requires review.
    • Include the member’s alpha prefix and number (i.e., ABC123456789, no spaces).
    • When you're checking a patient's eligibility and the system says "No authorization required,” take a screenshot in case of retrospective review.

    Outpatient rehabilitation codes

    Check our code list to view outpatient rehabilitation codes.

    Clinical guidelines

    eviCore healthcare occasionally updates their clinical guidelines. Please review the guidelines with your staff and make sure you're using the most current version. Questions? Call eviCore healthcare at 800-792-8751.

    More information

    To create an account and/or initiate an authorization:

    Visit eviCore healthcare for:

    • Orientation, CorePath training, tutorials (under Resources)
    • Quick reference guides
    • Clinical guidelines
    • FAQ
    • CPT code list
    • Medical necessity review authorization request (available through the clinical certification online tool)
    • Sign in to review your performance summary reports

    eviCore healthcare is an independent company managing outpatient rehabilitation services for LifeWise providers.