Independence constantly evaluates its policies, procedures, and requirements to ensure our members remain at the center of all we do. We use best practice standards and industry benchmarks to address where we are outliers in terms of cost and utilization. In some cases, these evaluations uncover areas in need of change. After thorough analysis of our members’ utilization and provider billing patterns, physical therapy (PT) and occupational therapy (OT) have been identified as services in need of modified precertification requirements.

Summary of changes

Effective January 1, 2020, providers will need to adhere to the following changes to PT and OT precertification requirements for Medicare Advantage members in order for their claims to be paid:

• Combined PT and OT visits 1 – 40: Although precertification is not required for these visits, providers will still need to notify the Independence Utilization Management department for those Medicare Advantage members they plan to treat. However, clinical information will not be required at the time of notification.
• Combined PT and OT visits 41 and above: Providers will need obtain precertification for these visits as well as submit clinical information to Independence for those Medicare Advantage members they plan to treat.
• Site of service: Notification/precertification will be required for services performed in the office, an outpatient hospital setting, and comprehensive outpatient rehabilitation facilities.
• CPT^® code exceptions: Notification/precertification will not be required for the following initial evaluation or re-evaluation CPT codes:

Learn more

Providers directly impacted by this change will receive a letter from Independence in the coming weeks with further instructions, and more information will be published in a future article in Partners in Health Update^SM. 

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