Outpatient Rehabilitation Therapy

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Physical Therapy

Physical therapy (PT) and occupational therapy (OT) services are typically a combined benefit under a member's short-term rehabilitation therapy benefits.

Note:

All physical therapists and occupational therapists employed by a group practice must contract with us.
Notifications to a PT or OT group cover only contracted providers. Non-contracted PTs and OTs can’t render services to a member, even if a continued stay is granted to the group provider NPI.

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How many visits are included in the initial notification?

Benefits and benefit limits vary by account. Please check the member’s benefits and eligibility before rendering services.

For these members	You can request	Within this time period
Commercial HMO/POS	Up to 26 PT visits and up to 26 OT visits per provider	Per calendar year.
Medicare HMO Blue and Medicare PPO Blue	Up to 12 visits each for PT and OT	Per 365-day period.

For Federal Employee Program members, no notification or continued review is required. However, benefit limits apply for physical therapy, occupational therapy and speech therapy combined.

How do I notify Blue Cross of initial PT/OT services?

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.

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

How to request a continuation of services

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. 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: HMO/POS 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. The member's PCP or an authorized specialist can call 1-800-327-6716 to request approval for an initial evaluation OR The physical or occupational therapist may 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.
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:

HMO/POS 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.

The member's PCP or an authorized specialist can call 1-800-327-6716 to request approval for an initial evaluation OR
The physical or occupational therapist may 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.

Check the status of your notification or continued review request

You can:

Use an electronic technology like Authorization Manager.
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 or practice. Enrolled providers receive a Daily Inpatient and Outpatient Notification Report via fax.

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.

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