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PT/OT/ST Outpatient Prior Authorization for Medicare Advantage Plans

A.

Prior-Authorizations are required for Physical Therapy, Occupational Therapy and Speech Therapy (PT, OT and ST) services rendered in the following settings: Office, Outpatient Hospital, Comprehensive Outpatient Rehabilitation Facilities and Home.

A. For Home Service and Non-Participating Outpatient Providers, authorization is required

 

A.

Re-evaluations require an authorization. The re-evaluation codes are included in the Outpatient bundled group codes (PT- 97110, OT- 97530).

A.

Group codes are sets of codes that encompass multiple codes for Outpatient PT and OT services under one all-inclusive designation for each type of Therapy. Authorization requests should include the group code 97110 for Physical Therapy (PT) requests and 97530 for Occupational Therapy (OT) requests.

A. The covered codes are:
95992
97002
97010
97012
97014
97016
97018
97022
97024
97032
97034
97035
97110
97112
97113
97116
97124
97140
97150
97164
97530
97760
97761
97762
A.

The covered codes are:
97004
97010
97014
97016
97018
97022
97024
97032
97034
97035
97110
97112
97124
97140
97150
97168
97530
97533
97535
97537
97760
97761
97762

A. You should list the code separately on your authorization request. Please note that any codes not included in the bundle will be sent to a clinical/medical director to be reviewed.
A.

You must submit a separate authorization requests, for each service.

A. All authorization requests should be submitted using Care Affiliate. You can access Care Affiliate through NaviNet.net, and select Horizon BCBSNJ from the My Health Plan Menu, then:

 

  • Mouse over Referrals and Authorizations
  • Select Utilization Management Requests
  • A.

    You can get to Care Affiliate via NaviNet, under Utilization Management Requests. If you cannot submit online, you may call for your authorization.

  • For Outpatient Therapy call 1-800-682-9094 extension 81623
  • For Home Therapy call 1-800-682-9094 extension 81366
A.

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)
A. If there is an issue specific to NaviNet, please contact NaviNet at 1-888-482-8057. If you can get into NaviNet but are having issues with the Care Affiliate application, please email CareAffiliate@HorizonBlue.com or call 1-888-777-5075..
A.

Prior authorization requests may take up to 14 days to process. Authorization requests that are submitted as a post service request (meaning the request was submitted after the start date of service) may take up to 30 days to process.

A.

You can request up to 12 visits for the initial authorization and subsequent re-authorization for outpatient therapy services. You can request up to 8 visits for the initial authorization and 6 visits for subsequent re-authorizations for home care therapy services

A.

No, treatment CPT codes are not reimbursed on the day of the initial evaluation. The initial evaluation visit is only to be for the evaluation.

 

A.

Yes, for the initial authorization, you must provide a signed copy of the therapy evaluation by the licensed participating therapist.

A. Examples of required clinical documentation include; an updated plan of care, therapist notes and/or re-evaluations containing subjective, objective, functional outcome data which support medical necessity and justify the need for skilled services. Dated and signed office notes or daily treatment flow sheets are considered to be acceptable proof.
A. A request for subsequent authorization visits can be submitted once the member has completed 80% of the previously approved visits. A re-evaluation must accompany this request

 

A.

When submitting via NaviNet/Care Affiliate, you can attach the documents direct to the new request. Care Affiliate can accommodate various file types such as PDF, JPG, Word etc.

A. You can check via NaviNet/Care Affiliate under Utilization Management Request Tool. You can check for the authorization status by:

 

  • Reference number
  • Provider ID
  • Member ID
A. Authorizations for:
  • Outpatient therapy services are for a 90 day period.
  • Home care therapy services are for 60 day period.
A.

Call Horizon BCBSNJ for assistance.

  • For Outpatient Therapy call 1-800-682-9094 extension 81623
  • For Home Therapy call 1-800-682-9094 extension 81366