Speech therapy services can sometimes be a combined benefit under an HMO/POS member’s short-term rehabilitation therapy benefits. For members of our Medicare HMO Blue Plan only, we require authorization for the initial 30 visits.
- All speech therapists employed by a group practice must contract with us.
- Authorizations to a speech therapy group cover only contracted providers. Non-contracted speech therapists can’t render services to a member, even if an authorization is granted to the group provider NPI.
When a patient needs speech therapy, their primary care provider (PCP) or an authorized specialist is responsible for generating an auto-approved initial authorization for the first 30 visits, every 365 days.
To do this, the PCP or specialist will need to use a technology. If the member’s maximum visits have already been met for the 365-day authorization period, a message will be displayed.
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.
| If | Then |
|---|---|
| The speech therapist determines that care beyond the initial 30 visits is needed |
|
| The member has a new episode of care within the same 365-day period and the first 30 visits have been used |
The authorization decision will be based on medical necessity criteria. |
To learn the status of an authorization, 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/practice. Enrolled providers receive a Daily Inpatient and Outpatient Notification Report via fax.
We use Centers for Medicare & Medicaid Services (CMS) criteria. Please refer to the Medicare Benefit Policy Manual.
