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We’re updating the initial authorization process for PT and OT
December 4, 2019

This article is for:

  • Primary care providers
  • Specialists
  • Occupational therapists (hospital-based and independently practicing providers and their group practices)
  • Physical therapists (hospital-based and independently practicing providers and their group practices)

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.

What’s changing?

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
  • Access Blue
  • Access Blue New England (with a Massachusetts PCP)
  • HMO Blue
  • New England Health Plan (with a Massachusetts PCP)
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.

How should the visits be requested?

As a reminder:

  • Requests for PT and OT should be entered electronically. Please request only the number of visits that the member needs for PT and OT services combined.
  • Requests for habilitative visits must be made by calling or faxing our Clinical Coordination area. The PCP or authorized specialist can contact us for this request.

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).

What if the member requires more than 26 visits for PT/OT?

Physical therapists and occupational therapists will follow the same process in place today to request an extension. This includes:

  • Sending the authorization extension request at least one week before the member’s last covered visit.
  • Attaching a copy of the initial evaluation and script.
  • Attaching progress and/or daily notes including symptoms/subjective information, objective updates and functional progress and continued limitations.
  • Including information regarding member’s most recent or next scheduled medical appointment with ordering physician. This is especially important if there is a lack of progress or decline.
  • Attaching a copy of the functional questionnaire.

What if the member requires visits at a new clinic or for a new discipline and the initial 26 visits have already been approved in the calendar year?

  • The PCP/authorized specialist must call our Clinical Coordination area for an evaluation only.
  • The new provider will need to send in an extension request to include an initial evaluation and the current script.

We’ll perform a medical necessity review based on the information received.

Resources

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.

Questions?

Please call our Clinical Coordination area at 1-800-327-6716.

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