East Bay Functional Restoration (EBFR) - Making Referrals Insurance Information

Making Referrals
Insurance Information

Insurance Information
EBFR accepts all Workers’ Compensation insurance carriers.

Patients with non-industrial Health Insurance (for example, Blue Cross, Blue Shield, Aetna, Medicare, etc., as well as other HMOs and PPOs) may have insurance coverage for portions of the EBFR program including Physical Therapy and the Pain Education and Coping Skills Group. But at this time, non-industrial Health Insurance Companies are not covering the full functional restoration program. To explore the availability of limited EBFR services please contact the EBFR Administrative Coordinator, Cynthia Clay, to discuss insurance coverage questions at 925-246-9930.

Making Referrals to EBFR
Workers’ Compensation Patients: Patients must have a written referral from the industrial Treating Physician. After written referral is received (either on an Rx form or in letter form) the EBFR administrative staff will takeover management of the authorization process.

Referrals may be faxed to EBFR at 925-246-9910.
To speak directly to the EBFR staff, please call 925-246-9930.

Enrollment in EBFR requires an initial evaluation by the EBFR Treatment Team. A comprehensive report of the EBFR evaluation will be sent to the referring Treating Physician and the insurance carrier. If the patient is an appropriate EBFR candidate, the Treating Physician must indicate in writing agreement with the recommended EBFR treatment plan. The EBFR staff will handle the necessary paperwork and communication with the Treating Physician at each step in the authorization process.

Insurance Authorization Denials
When there are denials, the following steps can be taken to facilitate the appeal:

1. Denial of the initial referral for an EBFR screening evaluation:

On occasion, the insurance carrier may ask for additional information about the EBFR program. Simply fax the denial letter to EBFR and we will provide the carrier with the necessary information.
Some denials are based on inadequate documentation of medical necessity. In this instance we recommend using some variation of the following language in the Treating Physician’s appeal letter:

This patient’s current presentation of chronic pain, impaired functional capacity, and delayed recovery clearly meets ACOEM guidelines (see page 114) for appropriate patient selection for multidisciplinary functional restoration. Specifically, his/her pain is attributable to a physical cause (may include some discussion of psychological overlay if relevant), previous methods of treating the chronic pain have been unsuccessful, a multidisciplinary approach would likely be beneficial, and the patient has a significant loss of ability to function independently from the chronic pain. As the Treating Physician, I am now requesting authorization for an evaluation by the EBFR Team to confirm my impression that multidisciplinary functional restoration is necessary. If theEBFR Team agrees that this patient is a good functional restoration candidate, their report will outline in detail the treatment goals and details about the proposed treatment. (May be useful to add further discussion about any complicating factors such as depression, not a good surgical candidate, medication overuse, etc.)

2. Denials after EBFR Team evaluation has been submitted to insurance carrier.

In this instance, the EBFR Team will submit an appeal and handle the necessary reports and paperwork, coordinating with the Treating Physician as necessary.