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Outpatient Rehabilitation Therapy

Habilitation services are health care services that help a person keep, learn, or improve skills and functioning for daily living.

Some members have outpatient benefits for habilitation care that are separate from their benefits for rehabilitation care.

For HMO members, authorization is required for these services.

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How to determine if a member has separate habilitation services benefits

To determine if a member has separate habilitation benefits, perform an eligibility inquiry in ConnectCenter using the Service Type, "Physical Therapy" or "Occupational Therapy." When the member has separate benefits, the Message column in your results will list Rehabilitation and Habilitation separately as shown in the screenshot below.


How to request authorization for HMO members

To request an initial authorization for habilitation services, the PCP or authorized specialist should call Clinical Intake at 1‑800-327-6716. We'll work with you to get an authorization for up to 26 PT/OT (combined) visits in the current calendar year.

To request an extension of an existing authorization, the PCP or authorized specialist should fax us a completed Habilitative Therapy Request Form for HMO Members.

When an HMO member receiving habilitation services also needs outpatient rehabilitation
If the member's benefits are The PCP or authorized specialist can
Combined Call Clinical Intake at 1-800-327-6716 to request an evaluation visit. Then, if additional visits are needed, we’ll need supporting documentation. Please follow the process for obtaining an outpatient rehab authorization extension for physical therapy or occupational therapy.
Separate Use Authorization Manager to enter an authorization for an initial 26 PT/OT (combined) visits. The authorization period is the current calendar year.
When an HMO member receiving outpatient rehabilitation also needs habilitation services
If the member's benefits are The PCP or authorized specialist can
Combined Call Clinical Intake at 1-800-327-6716 to request an evaluation visit. Then, if additional visits are needed, we’ll need supporting documentation. Please fax us a completed Habilitative Therapy Request Form for HMO Members.
Separate Call 1-800-327-6716 to request an authorization for an initial 26 PT/OT (combined) visits. The authorization period is the current calendar year.
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Who needs a occupational therapy authorization?

Occupational therapy (OT) and physical therapy (PT) services are typically a combined benefit under a member's short-term rehabilitation therapy benefits. Authorization is required for members in the following plans:

  • HMO
  • POS
  • Medicare HMO Blue
Note: 
  • All occupational therapists employed by a group practice must contract with us.
  • Authorizations to a occupational therapy group cover only contracted providers. Non-contracted occupational therapists can’t render services to a member, even if an authorization is granted to the group provider NPI.

 

How many visits are included in the initial authorization?

Reminder: Benefits and benefit limits may vary by account. As always, please check the member’s benefits and eligibility before rendering services.

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

When a patient needs occupational or physical therapy, the member’s primary care provider (PCP) or an authorized specialist is responsible for requesting initial authorization for combined PT/OT visits. (Note: For Medicare Advantage members, only the PCP may submit outpatient rehabilitation therapy authorization requests.)

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. Be sure that you enter the appropriate group PT/OT NPI number. If the member’s maximum visits have already been met for the authorization period, a message will be displayed.

When the request is made electronically, we will automatically approve the initial visits. All authorizations processed in the current authorization period will have the same end date as the initial authorization.

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.

How to obtain an extension authorization
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 authorization extension for additional services.
  • Submit the following items:
    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.
  • Enhance provider collaboration: submit to the PCP or specialist an updated plan of care for confirmation of the medical necessity of continued care.
Important:
  • If more visits are required beyond the approved extensions, HMO/POS members will have to pay for them.
  • Remember, before you provide 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 with the same provider within the same authorization period and the first visits have been used A new initial evaluation is needed.
  • The member's PCP or an authorized specialist can call 1-800-327-6716 to request authorization for an initial evaluation OR
  • The occupational or physical therapist may request authorization for an initial evaluation by submitting:
    1. A physician prescription AND
    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.
  • Enhance provider collaboration: submit to the PCP or specialist an updated plan of care for confirmation of the medical necessity of continued care.

The authorization decision will be based on medical necessity criteria.

Check the status of your authorization request

To learn the status of an authorization, you can:

  1. Use an electronic technology like Authorization Manager.
  2. 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.
Clinical criteria we use to review your request

For all members except Medicare HMO Blue:

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 InterQual Criteria & SmartSheets() page for information about how to access these criteria.

For Medicare HMO Blue members:

We use Centers for Medicare & Medicaid Services (CMS) criteria. Please see the Medicare Benefit Policy Manual.

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
     Habilitation Services

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.

Expand All
Who needs a physical therapy authorization?

Occupational therapy (OT) and physical therapy (PT) services are typically a combined benefit under a member's short-term rehabilitation therapy benefits. Authorization is required for members in the following plans:

  • HMO
  • POS
  • Medicare HMO Blue
Note: 
  • All physical therapists employed by a group practice must contract with us.
  • Authorizations to a physical therapy group cover only contracted providers. Non-contracted physical therapists can’t render services to a member, even if an authorization is granted to the group provider NPI.

 

How many visits are included in the initial authorization?

Reminder: Benefits and benefit limits may vary by account. As always, 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 Up to 12 visits each for PT and OT Per 365-day authorization period.
How to obtain initial authorization

When a patient needs physical or occupational therapy, the member’s primary care provider (PCP) or an authorized specialist is responsible for requesting initial authorization for combined PT/OT visits. (Note: For Medicare Advantage members, only the PCP may submit outpatient rehabilitation therapy authorization requests.)

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. Be sure that you enter the appropriate group PT/OT NPI number. If the member’s maximum visits have already been met for the authorization period, a message will be displayed.

When the request is made electronically, we will automatically approve the initial visits. All authorizations processed in the current authorization period will have the same end date as the initial authorization.

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.

How to obtain an extension authorization
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 authorization extension for additional services.
  • Submit the following items:
    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.
  • Enhance provider collaboration: submit to the PCP or specialist an updated plan of care for confirmation of the medical necessity of continued care.
Important:
  • If more visits are required beyond the approved extensions, HMO/POS members will have to pay for them.
  • Remember, before you provide 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 with the same provider within the same authorization period and the first visits have been used A new initial evaluation is needed.
  • The member's PCP or an authorized specialist can call 1-800-327-6716 to request authorization for an initial evaluation OR
  • The physical or occupational therapist may request authorization for an initial evaluation by submitting:
    1. A physician prescription AND
    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.
  • Enhance provider collaboration: submit to the PCP or specialist an updated plan of care for confirmation of the medical necessity of continued care.

The authorization decision will be based on medical necessity criteria.

Check the status of your authorization request

To learn the status of an authorization, you can:

  1. Use an electronic technology like Authorization Manager.
  2. 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.
Clinical criteria we use to review your request

For all members except Medicare HMO Blue:

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 InterQual Criteria & SmartSheets() page for information about how to access these criteria.

For Medicare HMO Blue members:

We use Centers for Medicare & Medicaid Services (CMS) criteria. Please see the Medicare Benefit Policy Manual.

Expand All
Who needs a speech therapy authorization?

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.

Note: 
  • 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.

 

How to obtain initial authorization for the first 30 visits

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

No authorization is required for members of the Federal Employee Program. However, benefit limits apply for Physical Therapy, Occupational Therapy and Speech Therapy combined.

How to obtain an extension authorization
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.

Check the status of your authorization request

To learn the status of an authorization, you can:

  1. Use an electronic technology like Authorization Manager.
  2. 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.
Clinical criteria we use to review your request

We use Centers for Medicare & Medicaid Services (CMS) criteria. Please refer to the Medicare Benefit Policy Manual.