Outpatient Rehabilitation Therapy

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Physical Therapy

Occupational therapy (OT) and physical therapy (PT) services are typically a combined benefit under a member's short-term rehabilitation therapy benefits. Benefits and benefit limits vary by account. Please check member’s benefits and eligibility before rendering services.

Coverage requests

Commercial EPO, HMO, POS, PPO	No review or notification is required for the first 16 visits.
Medicare HMO Blue and Medicare PPO Blue	You must notify us of the initial 16 visits.
Federal Employee Program	No notification or continued review is required.

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If more than 16 visits are needed for commercial members

The physical or occupational therapy provider must request medical necessity review if more than 16 visits are needed. This is required for each service type distinctly (for example: 16 physical therapy visits, 16 occupational therapy visits).

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 extension for additional services using Authorization Manager. OR Submit: A completed Short-Term Rehabilitation Therapy Extension Request Form. (Click here for a guide to completing the form.) Supporting documentation: the member's treatment plan, initial evaluation, and updated progress notes. An updated plan of care to the PCP or specialist to confirm that continued care is medically necessary. Important: Commercial members who have reached their benefit limit will need to pay for additional visits. Before providing 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 benefit or continued review period	A continuation review is needed. If visits remain, the therapist may use the remaining visits to treat all conditions and submit clinical information related to all conditions being treated on the next extension request. If no visits remain, the therapy provider should request approval for an initial evaluation by submitting: A physician prescription A partially-completed Short-Term Rehabilitation Therapy Extension Request Form. (Click here for a guide to completing the 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. Submit to the PCP or specialist an updated plan of care for confirmation of the medical necessity of continued care. The extension decision will be based on medical necessity criteria.

Then

The therapist determines that care beyond the initial visits is needed

At least one week prior to the last covered visit, request an extension for additional services using Authorization Manager.

Submit:
1. A completed Short-Term Rehabilitation Therapy Extension Request Form. (Click here for a guide to completing the form.)
2. Supporting documentation: the member's treatment plan, initial evaluation, and updated progress notes.
3. An updated plan of care to the PCP or specialist to confirm that continued care is medically necessary.

Important:

Commercial members who have reached their benefit limit will need to pay for additional visits.
Before providing 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 benefit or continued review period

A continuation review is needed.

If visits remain, the therapist may use the remaining visits to treat all conditions and submit clinical information related to all conditions being treated on the next extension request.

If no visits remain, the therapy provider should request approval for an initial evaluation by submitting:
1. A physician prescription
2. A partially-completed Short-Term Rehabilitation Therapy Extension Request Form. (Click here for a guide to completing the 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.
Submit to the PCP or specialist an updated plan of care for confirmation of the medical necessity of continued care.

The extension decision will be based on medical necessity criteria.

For Medicare Advantage members

For Medicare Advantage HMO members: The member's primary care provider (PCP) or an authorized specialist is responsible for notifying us that PT/OT visits are requested. (Note: For Medicare Advantage members, only the PCP may submit outpatient rehabilitation therapy notifications.)

An authorized specialist is a specialist who has an open referral from the member's PCP or is in the PCP's referral circle with no open referral.

To do this, the PCP or specialist will need to submit the request electronically and we will automatically acknowledge the initial visits:

Authorization Manager. Follow the instructions in our Quick Tip and User Guide.
Direct Connection.

For Medicare Advantage PPO members: The servicing therapy provider can submit the initial request.

Be sure to enter the appropriate PT/OT NPI number. A message will be displayed if the member’s maximum visits have been met for the notification period.

Check the status of your medical necessity or continuation review

Use an electronic technology like Authorization Manager or the Authorization Quick Lookup tool.

Clinical criteria we use to review your request

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 Clinical Criteria Overview page for information about how to access these criteria.

For Medicare HMO Blue and Medicare PPO Blue members, we use Centers for Medicare & Medicaid Services (CMS) criteria. Please see the Medicare Benefit Policy Manual.

Note:

Be sure to enter the appropriate NPI number. A message will be displayed to confirm if the member is at or near completion of the initial 16 visits.
All physical therapists and occupational therapists employed by a group practice must contract with us. Notifications to a PT/OT group cover only contracted providers.
If the servicing therapy provider is out-of-network, PCPs please attach the Out of Network request form to your request.

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