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We are updating our initial authorization process for physical therapy (PT) and occupational therapy (OT) services, effective for dates of service on and after January 3, 2020. This change applies only to new authorizations for the members listed below. If you have an existing authorization with remaining visits, you do not need to request a new authorization.
The member’s primary care provider (PCP) or authorized specialist designated by the member’s PCP will authorize the initial combined PT and OT visits as follows:
|For these members||You can request||Within this time period|
||Up to 26 combined PT/OT visits.||Per calendar year.|
Note: Previously, we allowed up to 16 combined PT/OT visits in a 365-day period.
As a reminder:
Best practice tip:
You don’t need to request all 26 visits on the first electronic submission. If this is a new PT or OT service request, we recommend asking for fewer visits (for example eight to twelve visits based on the member’s clinical picture). Then, if the member needs additional visits (up to 26), more can be added to the current authorization(s) or a new authorization can be entered based on the member’s needs (for example, if they go to a different discipline or a different office location that’s more convenient for them).
Physical therapists and occupational therapists will follow the same process in place today to request an extension. This includes:
We’ll perform a medical necessity review based on the information received.
For additional information on the PT and OT authorization process, please refer to our Physical Therapy and Occupational Therapy pages. We’ll update this information on January 3, 2020 to reflect the changes notes above.
Please call our Clinical Coordination area at 1-800-327-6716.