Pain Management Services Frequently Asked Questions

A. eviCore conducts Prior Authorization and/or Medical Necessity Determination (PA/MND) reviews of certain pain services.

A. For the Pain Management Program services, eviCore provides Utilization Management (UM) review (through either a PA/MND review), First Level UM appeals processing and UM-related customer service support.

A. eviCore reviews PA/MND requests in accordance with the clinical guidelines adopted by Horizon BCBSNJ.

A. For pain management services rendered in New Jersey, the program applies to:

• Horizon HMO
• Horizon Direct Access (DA)
• Horizon EPO
• Indemnity/Traditional
• Medicare Advantage
• OMNIASM Health Plans
• Horizon POS
• Horizon PPO
• State Health Benefits Plan (SHBP) NJ Direct
• Level Funded Plans
• Horizon Value Access

Note: This program does not apply to the Federal Employee Program® (FEP®), Medigap, Medicaid or Dual-Eligible Special Needs (DSNP) plans.

A. Please call Horizon BCBSNJ’s Physician Services at 1-800-624-1110. Members should call the Member Services number on the back of their Horizon BCBSNJ ID card for benefit verification.

A. The PA/MND process requires participating and nonparticipating health care professionals to request a review for any proposed course of treatment involving pain management services. Health care professionals should always contact eviCore to obtain a PA/MND prior to rendering services to ensure that the proposed services are medically necessary and therefore will be covered by the plan.

If a PA/MND is not obtained, claims may be delayed or denied pending our receipt of the information needed to establish medical necessity. There are three possible outcomes as a result of the PA/MND review:

• Approved: the complete treatment requested meets the criteria for medical necessity.
• Partial Approval: only part of the treatment requested is approved and the remainder is denied.
• Denied: the complete treatment does not meet clinical criteria and is denied.

For Inpatient Admissions: PA is required as determined by the member’s benefits.

For Outpatient Services: PA is required as determined by the member’s benefits. Where member benefits do not require a PA, a pre- or post-service MND review will apply.

A. The specific pain management services included in this program are identified in our online procedure code lists.

A. General requests for Commercial plans/products will be resolved within three business days, if all necessary clinical information is supplied. General requests for Medicare Advantage plans/products will be resolved no later than 14 calendar days after receipt of the request.

A. Access the pain management guidelines access the Horizon BCBSNJ Medical Policy Manual at HorizonBlue.com/ medical policy. You can also view this information on the Pain Management tab of this program’s webpage.

Services for this program can be administered at an:

• Office
• Outpatient facility
• Ambulatory surgical center

A health care professional should obtain a PA/MND upon determining the patient’s treatment plan for a pain service. It is important that PA/MND is obtained prior to delivery of the services to ensure coverage.

Services that are considered not medically necessary when reviewed on a post-service basis will not be covered or reimbursed by Horizon BCBSNJ.

A. Yes. If an Anesthesiologist needs to be included in a pain management procedure, a separate PA/MND (separate from the Pain Specialist’s PA/MND) must be requested and approved for the services of the Anesthesiologist.

Claims submitted for anesthesia services related to a pain management procedure will not be paid if there a valid authorization is not on file.

A. A rendering or ordering participating health care professional can initiate a PA/MND review by:

• Visiting eviCore’s secure website.
• Calling eviCore directly at 1-866-241-6603, Monday through Friday, 7 a.m. to 7 p.m., Eastern Time (ET). Multiple requests can be handled with one call. Urgent requests must be initiated by phone and identified as urgent by calling 1-866-241-6603. Representatives are available after hours and on weekends.

A. No. Requests should be initiated online or by phone.

See also the response to the question above: “How does a health care professional initiate a PA/MND?”

A. The health care professional should have the following information:

• Ordering health care professional name, address and office phone number
• Rendering health care professional name, address and office phone number (if different from ordering health care professional)
• Rendering facility name, NPI, Tax Identification Number (TIN), address and fax number
• Member name, date of birth and member ID number
• Anticipated start date of treatment
• Member height, weight and body surface area
• Procedure code and description
• Diagnosis (ICD-10 code)
• Past therapeutic failures including physical therapy, interventional pain procedures, medications and any other conservative treatment
• When applicable, co-surgeon and assistant surgeon information: name, Federal Tax Identification Number (FTIN) and participation status with Horizon BCBSNJ
• Relevant Diagnostic/Imaging result

A. Yes. The ordering or rendering health care professional may request a Peer-to-Peer consultation after the case has been requested by calling eviCore at 1-866-241-6603, Monday through Friday, from 7 a.m. to 7 p.m., ET. A Peer-to-Peer consultation may take place at any time on approved or denied requests. It can be scheduled or completed in real time.

A. The ordering or rendering health care professional (if applicable) will receive a copy of the determination letter. The PA/MND determination may be viewed at eviCore.com or the health care professional can call eviCore at 1-866-241-6603 and select the Customer Service option.

A. If eviCore does not have all of the necessary clinical information to make a determination, the PA/MND request will be pended for clinical review and the ordering or rendering health care professional will be given a case number. eviCore will place the case on hold and request the additional clinical information needed to complete the review from the ordering or rendering health care professional’s office.

A. The ordering or rendering health care professional is responsible for obtaining the PA/MND and supplying all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review.

If the rendering health care professional, who is not the ordering health care professional, calls eviCore to initiate a PA/MND, eviCore will contact the ordering health care professional to obtain the necessary clinical information.

The clinical information must be provided regardless if the ordering and the rendering health care professional are the same.

You may check the status of the PA/MND determination by using the eviCore web portal, which is available 24/7 at eviCore’s secure website.

A. eviCore will email health care professionals the approval status of PA/MND requests that are initiated through its web portal. eviCore faxes notifications to health care professionals who initiate PA/MND requests by phone, and for those who initiate by web without a valid email registered on the portal.

A. Yes. An approval letter will be sent to the ordering health care professional. A denial letter will be sent to the ordering health care professional, facility and the member.

A. Yes. A request to change an existing approved PA/MND determination can be submitted by calling eviCore at 1-866-241-6603. The clinical staff will review the request and render a decision. eviCore would not typically update an authorization after the service has been performed. They will review it prior to the expiration date. It must meet medical necessity criteria to update an authorization.

A. No. Clinical trials are not a part of this program. Please call Horizon BCBSNJ’s Complex Case Management department at 1-888-621-5894 for clinical trials.

A. Non-urgent requests will be completed as soon as possible based on the urgency of the case, but no later than three business days from receipt of all required clinical information.

Urgent requests will be completed as soon as possible based on the urgency of the case, but no later than 24 hours from receipt of the request.

A. Yes, a user name and password are required to access the eviCore web portal eviCore’s secure web portal. The web portal remains the quickest, most efficient way to obtain information.

• At the top of the page, next to “LOGIN:” select PROVIDERS.
• After a one-time registration, you are able to initiate a case, check status, review guidelines, view PA/MND/eligibility and more.

If you have questions or need assistance, please contact the Web Portal Specialist for assistance by phone at 1-800-646-0418 (Option #2) or email at providerrelations@evicore.com

A. The case number is all numeric and assigned at the initiation of a request. A PA/MND number is not assigned until a final determination is made.

A. Yes. Physicians or other health care professionals can log in to eviCore.com and click Authorization Lookup. Then:

• Select the member’s health plan and enter the health care professional ID, TIN, office or health care professional’s name. These are required fields for this search.
• Enter the patient’s member ID and date of birth and click Search.

A. Yes. An approved PA/MND is valid for 45 days. Physicians can log in to eviCore.com and click Authorization Lookup for individual case details.

A. The PA/MND from eviCore is valid for the eligible services relative to and occurred/rendered in the:

• Inpatient facility
• Outpatient facility
• Ambulatory surgical center

Disclaimer: The PA/MND does not supersede member benefits. An authorization does not guarantee payment of services.

A. Claims should be submitted in the same manner as before. Pre-service PA/MND review is recommended to avoid claims processing delays.

A. If a claim is submitted without obtaining a pre-service PA/MND, then the processing of the claim will be delayed until a PA/MND review can be performed and medical necessity is established.

To expedite claims processing, the following information is needed:

• An approved PA/MND determination number
• The appropriate HCPCS code for the specific procedure being billed
• The itemized date(s) of service

A. If medical records are not received in the required timeframe, the claim will be denied and will remain denied until the requested clinical documentation is received.

One fax attempt will be made by eviCore to contact the ordering health care professional to obtain the necessary clinical information. If eviCore is unsuccessful in obtaining the necessary clinical information, then eviCore will request the necessary clinical information in writing and the health care professional will be given 25 days to submit the requested information.

A. Information on how to appeal a denial will be provided in the denial letter issued by eviCore. Generally, a health care professional may dispute a denial that was based on medical necessity as follows:

For members in plans that are part of the Pain Management Program, health care professionals should call eviCore at 1-866-241-6603.

Submit written appeals to:
eviCore healthcare
Attn: Appeals Coordinator
400 Buckwalter Place Boulevard
Bluffton, SC 29910

Phone: 1-866-496-6200
Fax: 1-866-699-8128

A. A health care professional may dispute a denied claims determination that is not related to a PA/MND (a decision not based on medical judgment) by calling Horizon BCBSNJ at:

• Physician Services: 1-800-624-1110
• Facility Centralized Service Center: 1-888-666-2535

Members can call Member Services at 1-800-355-BLUE (2583) or the number listed on the back of their member identification cards.

A. For an appeal involving a PA/MND, call eviCore at 1-866-241-6603. For a claim appeal not involving medical judgment, call Horizon BCBSNJ’s Physician Services at 1-800-624-1110.