Blue Care Network (BCBSM HMO) Outpatient Physical Therapy prior authorization requirements (2026)
What Blue Care Network (BCBSM HMO) generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Commercial, Medicare Advantage plans. Yes. Blue Care Network (BCBSM HMO) generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
Medical-necessity criteria Blue Care Network (BCBSM HMO) generally applies
Prior authorization required for outpatient PT treatment visits: eviCore by Evernorth (which absorbed the legacy Landmark Healthcare program) makes PT/OT/ST determinations for BCN commercial (all fully insured groups, self-funded groups, and individual coverage). The INITIAL EVALUATION does not require authorization (BCN change effective 5/27/2019); authorization with a treatment plan is required for treatment visits after the initial eval. eviCore applies its evidence-based therapy guidelines and tiers providers by claims-data performance (variable-intensity review, re-analyzed periodically).
Commonly required documentation
- Initial evaluation with objective findings and standardized outcome measures
- treatment plan with frequency/duration and measurable functional goals
- progress documentation for continued-care requests.
How to submit
- Method: eviCore provider portal
- Portal: eviCore
Sources & verification
Sources: BCBSM UM doc https://authorizations.bcbsm.com/docs/cm-um-pt-ot-st.pdf (June 2026); initial-eval exemption https://ereferrals.bcbsm.com/bcn/news/bcn-news-175.shtml. Visit-count granularity of eviCore approvals and current tier mechanics could not be verified publicly (legacy FAQ PDF is offline). [NEEDS CLINICAL SPOT-CHECK] View the source policy. Last verified 2026-07-09.
Frequently asked questions
Does Blue Care Network (BCBSM HMO) require prior authorization for Outpatient Physical Therapy?
Yes. Blue Care Network (BCBSM HMO) generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
What does Blue Care Network (BCBSM HMO) require to approve Outpatient Physical Therapy?
Prior authorization required for outpatient PT treatment visits: eviCore by Evernorth (which absorbed the legacy Landmark Healthcare program) makes PT/OT/ST determinations for BCN commercial (all fully insured groups, self-funded groups, and individual coverage). The INITIAL EVALUATION does not require authorization (BCN change effective 5/27/2019); authorization with a treatment plan is required … Always confirm against the current Blue Care Network (BCBSM HMO) policy.
How long does a Blue Care Network (BCBSM HMO) prior authorization take?
Turnaround varies by plan and submission method. Check the Blue Care Network (BCBSM HMO) portal for current timeframes.
Submitting Outpatient Physical Therapy to Blue Care Network (BCBSM HMO)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.