Occupational therapy (OT) and physical therapy (PT) services are typically a combined benefit under a member's short-term rehabilitation therapy benefits. Authorization is required for members in the following plans:
Reminder: Benefits and benefit limits may vary by account. As always, please check the member’s benefits and eligibility before rendering services.
|For these members||You can request||Within this time period|
|Commercial HMO/POS plans||Up to 26 PT and up to 26 OT visits per provider||Per calendar year.|
|Medicare HMO Blue||Up to 12 visits each for PT and OT||Per 365-day authorization period.|
When a patient needs occupational or physical therapy, the member’s primary care provider (PCP) or an authorized specialist is responsible for requesting initial authorization for combined PT/OT visits. (Note: For Medicare Advantage members, only the PCP may submit outpatient rehabilitation therapy authorization requests.)
|An authorized specialist is a specialist who has an open referral from the member's PCP or is in the PCP's referral circle.|
To do this, the PCP or specialist will need to use a technology. Be sure that you enter the appropriate group PT/OT NPI number. If the member’s maximum visits have already been met for the authorization period, a message will be displayed.
When the request is made electronically, we will automatically approve the initial visits. All authorizations processed in the current authorization period will have the same end date as the initial authorization.
Technologies you can use to submit your request
No authorization is required for members of the Federal Employee Program. However, benefit limits apply for Physical Therapy, Occupational Therapy and Speech Therapy combined.
|The therapist determines that care beyond the initial visits is needed||
|The member has a new episode of care with the same provider within the same authorization period and the first visits have been used||A new initial evaluation is needed.
The authorization decision will be based on medical necessity criteria.
To learn the status of an authorization, you can:
For all members except Medicare HMO Blue:
To make medical necessity decisions for initial authorization and extension requests, we use InterQual® Criteria and our medical policies, as described in the subscriber certificate. Visit our InterQual Criteria & SmartSheets() page for information about how to access these criteria.
For Medicare HMO Blue members:
We use Centers for Medicare & Medicaid Services (CMS) criteria. Please see the Medicare Benefit Policy Manual.