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. |
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 |
OR
Important:
|
| The member has a new episode of care within the same benefit or continued review period | A continuation review is needed.
The extension decision will be based on medical necessity criteria. |
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.)
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.
Use an electronic technology like Authorization Manager or the Authorization Quick Lookup tool.
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.
- 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.
Primary care providers (PCPs) and designated specialists with an open referral from the PCP can refer a member for short-term rehabilitation therapies, including:
Physical therapy
Occupational therapy
Speech therapy
In most instances, the benefit for Massachusetts managed care group members is 60 visits per member per calendar year. The 60-visit maximum combines benefits for physical therapy (PT) and occupational therapy (OT) services. Speech therapy (ST) benefits are generally not included in the combined PT/OT short-term rehabilitation benefit. However, some self-funded accounts do combine the three therapies into one benefit.*
As always, it’s important for you to verify member benefits and eligibility before performing services.
*The short-term rehabilitation visit limit for Preferred Blue PPO® and Preferred Blue PPO Basic Saver® is 60 visits. The 60-day outpatient rehabilitation benefit limit does not apply to Medicare HMO Blue.
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. |
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 |
OR
Important:
|
| The member has a new episode of care within the same benefit or continued review period | A continuation review is needed.
The extension decision will be based on medical necessity criteria. |
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.)
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.
Use an electronic technology like Authorization Manager or the Authorization Quick Lookup tool.
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.
- 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.
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.
