Total knee or hip joint replacement

Applies to:

All plans

Medicare plans follow Medicare coverage and billing rules

Joint replacement authorizations

Participating surgeons should use the online Auth Request tool to enter procedure codes and request authorization for total hip and total knee replacement. Auth Request will send the provider to eviCore healthcare to process the request.

Participating facilities should the online Auth Request tool to request authorization for inpatient procedures. Authorization will be facilitated through Clear Coverage™ when the member presents to the facility for surgery. The facility may use eviCore healthcare as their admission criteria in the Clear Coverage™ tool, depending on the procedure.

Non-participating providers should use our authorization forms.

Post-surgical therapy authorizations

Post-surgical therapy in a sub-acute rehab facility requires prior authorization. Approval is subject to medical criteria and based on the patient's needs at the time of hospitalization and discharge. Examples:

  • If a patient is walking several feet with an aide, the appropriate next level of care would be outpatient or in-home therapy.
  • Patients who are older with multiple co-morbidities and who have caregivers who are unable to provide assistance may need a brief stay in a sub-acute rehab facility.

Patient education recommendations

Your patients need all of the facts when considering surgery. For elective total knee and hip replacements, planning for pre- and post-acute care is also essential. Here are some steps we recommend to prepare your patients for optimal surgical outcomes.

Pre-surgery education

Register your patient to be emailed the Emmi® pre-surgical Total Knee Replacement and Total Hip Replacement education video.

Have your patient attend "joint camp" or a similar pre/post-surgery education session at your affiliate provider office or hospital.

Plan for care following surgery

A caregiver is necessary

Encourage the patient to plan for a caregiver at home following surgery.

Post-surgical therapy

Let your patient know that you'll arrange for therapy after surgery based on how well they do while still in the hospital.

You may refer your patient to therapy in an outpatient facility, in the patient's home or in a sub-acute rehab facility, depending on needs identified while the patient is in the hospital. (Note that literature indicates an increased risk of infection if transitioning to a sub-acute facility.)