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Who needs a physical therapy authorization?

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:

  • HMO
  • POS
  • Medicare HMO Blue
Note: 
  • All physical therapists employed by a group practice must contract with us.
  • Authorizations to a physical therapy group cover only contracted providers. Non-contracted physical therapists can’t render services to a member, even if an authorization is granted to the group provider NPI.

 

How many visits are included in the initial authorization?

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
  • Access Blue
  • Access Blue New England (with a Massachusetts PCP)
  • HMO Blue
  • New England Health Plan (with a Massachusetts PCP)
Up to 26 combined PT/OT visits Per calendar year.
Medicare HMO Blue and certain HMO/POS plans Up to 16 combined PT/OT visits Per 365-day authorization period.
How to obtain initial authorization

When a patient needs physical or occupational 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

  • Online Services()
  • Direct Connection()

For members of the Federal Employee Health Benefit Program, call Provider Service at 1-800-451-8124.

How to obtain an extension authorization
If Then
The therapist determines that care beyond the initial visits is needed
  • At least one week prior to the last covered visit, request an authorization extension for additional services.
  • Submit the following items:
    1. A completed Short-Term Rehabilitation Therapy Extension Request Form.
    2. Supporting documentation: the member's treatment plan, initial evaluation, and updated progress notes.
Important:
  • If more visits are required beyond the approved extensions, HMO/POS members will have to pay for them.
  • Remember, before you provide non-covered services, you must notify the member that the services are not covered and get the member’s prior written consent to be billed.
The member has a new episode of care within the same authorization period and the first visits have been used A new initial evaluation is needed.
  • The member's PCP or an authorized specialist can call 1-800-327-6716 to request authorization for an initial evaluation OR
  • The physical or occupational therapist may request authorization for an initial evaluation by submitting:
    1. A physician prescription AND
    2. A partially-completed Short-Term Rehabilitation Therapy Extension Request Form. On the form, indicate the need for one evaluation visit, and submit these sections:
      • Patient Information
      • Provider Information
      • Requested Services.
  • After the initial evaluation, if the therapist determines that care is needed, please submit a completed Short-Term Rehabilitation Therapy Extension Request Form with the evaluation for review.

The authorization decision will be based on medical necessity criteria.

Check the status of your authorization request

To learn the status of an authorization, you can:

  1. Use an electronic technology like Online Services().
  2. Enroll in our Automated Fax-back Program to receive daily notices of all service approvals and denials entered into our medical management authorization system for your facility/practice. Enrolled providers receive a Daily Inpatient and Outpatient Notification Report via fax.
Clinical criteria we use to review your request

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.