Regence Blue Shield Massage Therapy

All plans require that a prescription be written by a doctor.

As of June 7, 2018, the prior authorization requirements have changed.  Regence plans that formerly required prior authorization are now allowed to have 6 sessions of massage therapy without any prior authorization.  Here is the new law in full.  Sections 2) and 6) are most pertinent to massage therapy.

RCW 48.43.016

Prior authorization standards and criteriaHealth carrier requirementsDefinitions.

(1) A health carrier that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall inform an enrollee which tier an individual provider or group of providers is in by posting the information on its web site in a manner accessible to both enrollees and providers.

(2) A health carrier may not require prior authorization for an initial evaluation and management visit and up to six consecutive treatment visits with a contracting provider in a new episode of care of chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan. Notwithstanding RCW 48.43.515(5) this section may not be interpreted to limit the ability of a health plan to require a referral or prescription for the therapies listed in this section.

(3) A health carrier shall post on its web site and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions.

(4) A health care provider with whom a health carrier consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed or of a specialty whose practice entails the same or similar covered health care service.

(5) A health carrier may not require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party.

(6) For purposes of this section:(a) "New episode of care" means treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment.(b) "Contracting provider" does not include providers employed within an integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW.

After the initial 6 sessions are done, more sessions may be requested through prior authorization.  The prior authorization is done through a 3rd party hired by Regence called eviCore.     I take care of this process.  What it means is that I take the prescription and your plan details and plug them into eviCore's website and they will tell me how many sessions you can get for your massage therapy.  This ignores your plan benefits and the doctor's prescription.   What usually happens is that they allow 2 or 3 more sessions no matter what your condition is. 

What this means is that even though your insurance may allow 16 sessions and your doctor prescribes say 10 sessions or even the full 16 sessions, you get 6 sessions. 

All massage therapy must meet their definition of medical necessity which currently reads:

Medically necessary services are defined as a health care service or supply that a physician or other health care provider exercising prudent clinical judgment would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

  •  In accordance with generally accepted standards of medical practice 
  • Clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease
  • Not primarily for the convenience of the patient, facility, physician or other health care provider, and not more costly than an alternative service or sequence of services or supplies at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease

Taken from their website on July 29,2018.  (Regence Prior Authorization for Providers PDF)

What this means for patients is that massage therapy can not be provided just for pain only.  There has to be a loss of function which means you can't walk, sit or move or participate in some activity of daily living that you usually can complete normally.

If you do not meet the definition of medical necessity, I am unable bill your insurance.  You can see me and pay cash for your sessions.

Regence Uniform/ Regence King County

All plans require a prescription but Regence Uniform plans are exempt from prior authorizations along with a few other companies who are self insured which means they can set their own rules.  They are just using Regence to manage their own plans and are exempt from the usual rules insurance companies must follow.

This other companies that are currently excluded are:

  • Boeing
  • Medigap 
  • Kent Fire
  • KingCare
  • Pierce County
  • City of Tacoma
  • Uniform Medical Plan 
  • Federal Employee Plan 
  • Any member where we are in the secondary coverage position 
  • Regence Group Administrators (RGA)/Health Management Administrators (HMA)
  • BlueCard (Blue Cross Blue Shield members from other Plans who are not Regence members)
  • All AWC Employee Benefit Trust groups (with the exception of the AWC Staff Plan; group #10016119)
  • Note: Some Administrative Services Only (ASO) groups may be excluded. A member covered on one of these groups will be identified by CCN through the pre-authorization process

(This list is subject to change and plans may vary.  You and I will still need to confirm this with your insurance plan to be sure.)

What this means is that when the physician prescribes massage for a condition, it must now clearly be a condition where there is a loss of function (can't sit for X amount of time or Walk for X amount of time) AND a pain syndrome. 

It also means that the pre-authorization process limits the number of sessions that you can get to 4-6 sessions no matter what your benefits are and no matter what the injury/condition is.  It does not matter if the doctor prescribes more sessions and it does not matter how many sessions your plan allows.

Currently the physical therapists have initiated legislation that would stop this behavior which would also make it apply to massage therapists.

I suggest that you contact your insurance plan, your company's benefits co-coordinator and tell them what is happening.  Contact the Office of the Insurance Commissioner (they already know but the more complaints the more they will pay attention!)