As previously communicated in a
Partners in Health UpdateSM
article, 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 to 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:
|
Type of visit |
PT codes |
OT codes |
|---|
Evaluation: | | |
Re-evaluation: | | |
Notification/precertification process information
As of January 1, 2020, notifications should be made to the Utilization Management department by calling
1-800-ASK-BLUE![]( "Call: 1-800-ASK-BLUE")
(1-800-275-2583![]( "Call: 1-800-275-2583")
). Be advised that the prompts have changed for our Provider Automated System, please read this
article for additional details.
Notifications are
not able to be processed through the NaviNet® web portal (NaviNet Open) at this time.
Once the functionality is available through NaviNet Open, we will publish an article in
Partners in Health Update.
Learn more
If you have any questions regarding these changes, please contact Linda Slaughter, Manager Utilization Management at
215-241-9540![]( "Call: 215-241-9540")
.
CPT Copyright 2017 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association.
NaviNet® is a registered trademark of NantHealth, an independent company.