PT/OT Outpatient Prior Authorization for Horizon Medicare Advantage Plans
Q. What change is taking effect regarding prior authorizations for outpatient physical therapy and occupational therapy (PT/OT) for Horizon Medicare Advantage members?
Effective January 1, 2017, all Horizon Medicare Advantage member prior authorization requests for PT/OT services must be submitted via our online Utilization Management Request Tool (CareAffiliate) accessible on NaviNet®.
Authorization is not required for the initial evaluation (Physical Therapy Evaluation 97001 and Occupational Therapy Evaluation 97003).
Authorizations apply to services rendered in the following settings: office, outpatient hospital and comprehensive outpatient rehabilitation facilities.
This change applies to all Horizon Medicare Advantage plans, including members enrolled in the Horizon Medicare Advantage NJ DIRECT (PPO) plans.
Requests for all other Horizon BCBSNJ plans that require prior authorizations must continue to be submitted using our online Physical and Occupational Therapy Authorization Tool available on NaviNet.
This change will be effective January 1, 2017. All visits on or after this date will require PT/OT prior authorization requests to be submitted using our online Utilization Management Request Tool (CareAffiliate) accessible on NaviNet.
Q. What will be the process for current Horizon Medicare Advantage members who started treatment before January 1, 2017?
If a physician or other health care professional was previously given an authorization for a Horizon Medicare Advantage member prior to January 1, 2017, that authorization will be honored. Once all approved visits are used under that authorization and additional visits are needed/requested, the physician or other health care professional will be required to submit a new authorization request via our online Utilization Management Request Tool (CareAffiliate). This will ensure that the ongoing claims for the episode of care are processed. All authorization requests must include clinical documentation to justify ongoing medical necessity.
To ensure a quick turnaround, we recommend that you request the amount of visits that is medically necessary up to a maximum of 12 visits for both the initial authorization and subsequent reauthorization requests.
Q. If initial therapy evaluations do not require authorizations, is authorization required for re-evaluations (Physical Therapy Re-evaluation 97002 or Occupational Therapy Re-evaluation 97004)?
No authorization is required for re-evaluations.
Q. What can I expect regarding number of authorized visits per authorization over an episode of care?
We may only authorize up to 12 visits for the initial authorization and subsequent re-authorizations. Any authorization requests for subsequent visits beyond the first 12 visits will follow our medical necessity criteria and an appropriate number of visits will be authorized.
Q. If an evaluation and treatment were completed on the same day, would payment be received for the treatment, even if the authorization has not been submitted?
No. An authorization number must be received before treatment can begin and claims can be processed for payment.
To receive your initial authorization, you must provide a copy of the physical or occupational therapy evaluation.
All requests for subsequent visits will require the completion of a re-evaluation that contains subjective and objective evidence, including functional outcome measures that support medical necessity.
A request can be submitted once the member has completed at least 10 out of 12 previously authorized visits. A re-evaluation must accompany this request.
All authorization requests for Horizon Medicare Advantage members should be submitted using our online Utilization Management Request Tool (CareAffiliate). You can access this tool online. Log on to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu, then:
- Mouse over Referrals and Authorizations
- Select Utilization Management Requests
Our online Utilization Management Request Tool allows you to upload all clinical documentation directly to the request. The tool can accommodate various file types such as Word, Excel or PDF.
If there is an issue specific to NaviNet, please call NaviNet at 1-888-482-8057.
If you can get into NaviNet but are having issues with the online Utilization Management Request Tool, please email Provider_Portal@HorizonBlue.com or call 1-888-777-5075.
Online training is available. Log on to NaviNet, and select Horizon BCBSNJ from the My Health Plans menu then:
- Mouse over References and Resources and click Provider Reference Materials
- Mouse over Policies & Procedures and click Utilization Management
- Select Utilization Management Request Tool (CareAffiliate)
You can check the status of an authorization on our online Utilization Management Request Tool via NaviNet.
You can check for the authorization status by:
- Reference number
- Provider ID
- Member ID
The preferred method of requesting authorizations is through our online Utilization Management Request Tool on NaviNet. This method ensures that all of the supporting clinical information is received and provides the fastest turnaround time.
However, you can call our PT/OT Inquiry Unit:
- PT/OT authorizations for Horizon Medicare Advantage NJ DIRECT (PPO) members call, 1-855-742-78611 (option 1, then option 1 again)
- PT/OT authorizations for all other Horizon Medicare Advantage members call, 1-888-621-5894 (option 3, then option 1)
1 This number will be available for use beginning December 9, 2016.
Q. What is the turnaround time for processing a pre-service, non-urgent prior authorization request?
The turnaround time for processing a pre-service, non-urgent prior authorization request is 14 calendar days.
Yes. The timeframes are indicated in the authorization letter.
Q. How do I get an extension on the authorization period in the event the Horizon Medicare Advantage member cannot attend his or her their visits during the authorization period?
You can call our PT/OT Inquiry Unit. An Inquiry Team member will be able to extend the authorization period and a new letter will be faxed with the updated authorization period.
- PT/OT authorizations for Horizon Medicare Advantage NJ DIRECT (PPO) members call, 1-855-742-78611 (option 1, then option 1 again)
- PT/OT authorizations for all other Horizon Medicare Advantage members call, 1-888-621-5894 (option 3, then option 1)
1 This number will be available for use beginning December 9, 2016.
If you have any questions about these changes or the authorization process, please call our PT/OT Inquiry Unit.
- PT/OT authorizations for Horizon Medicare Advantage NJ DIRECT (PPO) members call, 1-855-742-78611 (option 1, then option 1 again)
- PT/OT authorizations for all other Horizon Medicare Advantage members call, 1-888-621-5894 (option 3, then option 1)
1 This number will be available for use beginning December 9, 2016.
