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.
| 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. 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
- Online Services()
- ANSI 278 through Emdeon
For members of the Federal Employee Health Benefit Program, call Provider Service at 1-800-451-8124.
| 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 Online Services().
- 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.
