This article is for occupational therapists, physical therapists and providers who refer patients for PT and OT services
Update issued January 26, 2026:
We have added information to clarify the review process for Medicare Advantage members and include reference to the Outpatient Rehabilitation Services payment policy.
Update issued February 16, 2026:
Added information on retroactive authorizations for 2025 dates of service.
Since communicating changes to our physical therapy and occupational therapy review process for coverage in 2026, we wanted to share a few reminders with you.
Primary care providers, providers of choice, or authorized specialists:
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For Commercial HMO, POS, PPO, and EPO members |
For Medicare Advantage members |
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You no longer need to notify us of PT/OT visit requests, but a prescription, written order, or updated signed plan of care from the ordering provider is required. Be sure to send that prescription to the PT/OT practice. |
You must notify us before the initial visit by entering an authorization request using Authorization Manager for PT/OT services. |
Physical therapy and occupational therapy providers and groups:
A new service process for commercial members takes effect on January 1.
- For commercial HMO/POS members: The first 16 visits will not require review or notification. Additional visits require a medical necessity review requested through Authorization Manager or by submitting our Short-Term Rehabilitation Therapy Extension Form (to be updated January 1, 2026). We recommend entering the request at least one week before the last covered visit.
- For commercial PPO/EPO members: Follow the same process as noted above for HMO/POS members for visits beyond the initial 16 visits.
Approved authorizations for commercial members are valid until the end of the calendar year, while those for Medicare Advantage members are valid for 365 days.
We’d also like to remind you that requests for out-of-network services always require authorization as of the first visit for HMO (managed care), EPO, and members with high performance networks.
Supervision requirements for reimbursement:
- Services performed by students, licensed physical therapy assistants (PTAs), or certified occupational therapy assistants (COTAs) must be supervised and have specific requirements for reimbursement.
- Services provided by a student and supervised by a PT or OT or their assistant are not reimbursed.
- Services provided by a PTA or COTA must also be supervised under direct, personal, and continuous supervision of a contracted physical or occupational therapist. These services are only reimbursed if rendered by a Blue Cross contracted PT or OT.
For more details, refer to our PT/OT - Independent Practice and General Coding and Billing payment policies.
For more details, and go to Office Resources>Payment Policies to refer to our PT/OT - Independent Practice and General Coding and Billing payment policies.
To request a retroactive authorization for dates of service in 2025, contact our Health and Medical Management department by calling 1-800-327-6716 and selecting option 3, or fax your request to 1-888-282-0780.
Resources
Resources
- Authorization Quick Tip
- Payment policies (login required):
- Outpatient Rehabilitation Services
- PT/OT - Independent Practice
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