Physical Therapy/Occupational Therapy Utilization Management Program FAQs November 2015

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1 Physical Therapy/Occupational Therapy Utilization Management Program FAQs November 2015 Background: Effective November 1, 2015, Anthem Blue Cross and Blue Shield (Anthem) implemented a physical therapy (PT) and occupational therapy (OT) benefit management program for outpatient and office services. In order to help us effectively administer this program, we have contracted with an external vendor, OrthoNet LLC, to work with us on this initiative. The program includes Indiana, Kentucky, Missouri, Ohio and Wisconsin. What is OrthoNet? OrthoNet is a leading musculoskeletal management company located in White Plains, NY. OrthoNet is a provider-based company with collaborative relationships with leading practitioners in the Anthem service areas. OrthoNet has significant experience in promoting best practices and evidence-based health care for therapy services. OrthoNet works with physical and occupational therapists as well as other providers of therapy services and their patients. When will providers be notified? Providers were sent an initial 90 day notification in July Follow-up information was included in the provider newsletter, Network Update, and online. What is OrthoNet's role in the review process? OrthoNet will receive all requests for office and outpatient physical and occupational therapy services and review those requests for medical necessity. Providers should contact OrthoNet for prior authorization requests. Providers will be notified by OrthoNet of the determination via mail and fax. How can providers contact OrthoNet? Members and providers may contact the OrthoNet call center at (fax: ) to begin the review process. The OrthoNet call center is open from 8am to 5:30pm in all time zones. What type of authorization will be required for PT/OT services? This PT/OT program requires a utilization management (UM) precertification review. All outpatient and office PT and OT services following the initial evaluation require precertification through OrthoNet. What providers are excluded from this program? Services rendered by the following providers are not reviewed in this program: Chiropractors, Acupuncturists, Massage Therapists, Home Health Centers or Agencies, and Skilled Nursing Facilities Inpatient Services. What settings are excluded from this program? Services rendered in the following settings are not reviewed in this program: services rendered as part of emergency room services, services rendered in a hospital inpatient setting, services rendered in an urgent care setting, services rendered as part of observation room services, services rendered in a home setting, and services rendered in a skilled nursing facility inpatient setting. What products are included in this program? Local Fully Insured Large Group, Small Group, and Individual products for both public and private exchange business including: HMO, PPO, POS, Traditional, and ASO (as a buy up option). Updated November

2 What products are excluded from this program? Products that are excluded include Medicare Advantage, Medicaid, Medicare supplement, Medicare Part D, Anthem National Accounts (ANA), Federal Employee Program (FEP ), and BlueCard. Who is responsible for obtaining an authorization from OrthoNet? - If a member is receiving care from an Anthem participating provider, that provider is required to secure the authorization from OrthoNet. - If a member is receiving care from a non-participating provider, the member is responsible for ensuring the nonparticipating provider secures the authorization from OrthoNet. - If a member is receiving care from an In Network provider located out of state (FL, TX, etc.) the member is responsible for ensuring the out of state provider secures the authorization from OrthoNet. How will providers know which members require an authorization? Providers can contact the Anthem Provider Services phone number on the back of the member s ID card for benefit information. They will be informed whether the OrthoNet program applies. OrthoNet will also have a list of the in-scope membership and will not provide precertification for members who are out of scope. If providers use ICR to precertify an outpatient PT/OT service, ICR will produce a message referring the provider to OrthoNet. What process should providers follow to request authorizations? Providers can request authorizations in two ways. 1. By fax: Providers may complete the OrthoNet Fax Request Form (containing the member s demographics and insurance information) and the PT/OT Initial Report Form or Functional Progress Chart (containing the member s supporting clinical information). These documents are available on the OrthoNet website, Providers may also use their own forms or clinical notes that will supply the same information. These documents need to be faxed to the OrthoNet Medical Management Automated Fax Request line, By Phone: Providers may contact the OrthoNet call center at in order to start the authorization request by supplying the member s information. The provider may then complete the PT/OT Initial Report Form or Functional Progress Chart (containing the member s supporting clinical information), available on the OrthoNet website, Providers may also use their own forms or clinical notes that will supply the same information. The provider will then complete the request by faxing these documents to the OrthoNet Medical Management Automated Fax Request line, Note: OrthoNet is currently working on capability for providers to submit authorization requests and check authorization status via website. These automated capabilities will be available in 2016 at What happens if the OrthoNet Fax Request Form and/or the clinical documentation are missing information? OrthoNet will call the provider to request the additional information. What are the levels of review for an authorization request? OrthoNet employs a variety of clinicians to render review requests (PTs, OTs, RNs, etc.). If a clinician reviews a particular case and is unable to approve the authorization request, the case is directed to a licensed MD or DO. That physician will review the medical necessity criteria along with all clinical information sent from the provider and will issue the determination according to his/her findings. Do providers who are currently in the middle of therapy treatment with a patient need to obtain authorization? Yes. Providers are required to obtain precertification for members already in a course of treatment for services that are scheduled to occur on and/or after date of service November 1, Updated November

3 Can providers request an authorization after a PT/OT service is provided? Yes. At this time, Anthem will continue to perform retrospective reviews as applicable in accordance with your contract. How are providers and members notified of the results of the request? OrthoNet will review the request and its supporting clinical data and assign an authorization number as appropriate within two business days of the receipt of all required clinical information. OrthoNet authorization numbers will be stored in the Anthem system. Providers will be notified via mail and fax of the authorization number and the number of visits approved. Members will be notified by mail. How can providers check the status of an authorization request? Providers can contact the OrthoNet call center at to check the authorization status. Does the initial PT/OT evaluation require precertification? No. The initial evaluation, or any associated therapy service(s) provided during that same visit, does not require review. To ensure proper reimbursement, initial evaluation codes below should be submitted on the claim. Code Description PHYSICAL THERAPY EVALUATION OCCUPATIONAL THERAPY EVALUATION Is the precertification number required to be submitted on the claim? No. Anthem s system will automatically align the claim with the appropriate authorization. How do authorizations get into the Anthem system electronically or manually? OrthoNet transmits a nightly authorization file to us Monday through Friday which is then loaded into the claims system. What are the precertification requirements when Anthem is the secondary insurer? Precertification is not required when Anthem is secondary to any commercial insurer or any Medicare product, program or plan. Are there any special billing requirements? Providers are requested to append modifier GP to all physical therapy services and to append modifier GO to all occupational therapy services when submitting claims on a CMS-1500 form for services delivered under an outpatient or office occupational or physical therapy plan of care. Providers billing on a UB-04 form are not required to bill with the GP or GO modifiers. What happens if a provider/member has an authorization from OrthoNet but the member s benefits have been exceeded? An authorization number is not a guarantee of payment. An authorization is a statement that the service meets the medical necessity requirements. Compensation is based on the provider s agreement with Anthem and terms of the member s health plan. How are member and physician appeals handled? Anthem will continue to handle all administrative and clinical appeals for members and providers. Will providers have access to the OrthoNet review criteria? If a provider receives a precertification denial, the provider can request the specific criteria applied to that member and OrthoNet will make it available. Will Anthem continue to process these claims? Yes. Anthem will continue to process all claims related to outpatient and office physical and occupational therapy services and provide member benefit and eligibility information. Updated November

4 Do we have a list of PT/OT procedure codes that will be subject to the precertification program? Yes. The codes subject to the precertification program are listed below. Please note that precertifications are given on a visit level and not at a procedure code level; therefore, the procedure codes that require precertification are for informational purposes only. Code Description PHYSICAL THERAPY EVALUATION PHYSICAL THERAPY RE-EVALUATION OCCUPATIONAL THERAPY EVALUATION OCCUPATIONAL THERAPY RE-EVALUATION APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HOT OR COLD PACKS APPLICATION OF A MODALITY TO ONE OR MORE AREAS; TRACTION, MECHANICAL APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION(UNATTENDED) APPLICATION OF A MODALITY TO ONE OR MORE AREAS; VASOPNEUMATIC DEVICES APPLICATION OF A MODALITY TO ONE OR MORE AREAS; PARAFFIN BATH APPLICATION OF A MODALITY TO ONE OR MORE AREAS; WHIRLPOOL APPLICATION OF A MODALITY TO ONE OR MORE AREAS; DIATHERMY (EG, MICROWAVE) APPLICATION OF A MODALITY TO ONE OR MORE AREAS; INFRARED APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRAVIOLET APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION(MANUAL), EACH 15 MINUTES APPLICATION OF A MODALITY TO ONE OR MORE AREAS; IONTOPHORESIS, EACH 15 MINUTES APPLICATION OF A MODALITY TO ONE OR MORE AREAS; CONTRAST BATHS, EACH 15 MINUTES APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HUBBARD TANK, EACH 15 MINUTES UNLISTED MODALITY (SPECIFY TYPE AND TIME IF CONSTANT ATTENDANCE) THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; AQUATIC THERAPY WITH THERAPEUTIC EXERCISES THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING) THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) UNLISTED THERAPEUTIC PROCEDURE (SPECIFY) MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), ONE OR MORE REGIONS, EACH 15 MINUTES THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS) THERAPEUTIC ACTIVITIES, DIRECT (ONE ON ONE) PATIENT CONTACT BY THE PROVIDER(USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING, (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER, EACH 15MINUTES SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER, EACH 15MINUTES Updated November

5 97535 SELF-CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF DAILY LIVING (ADL) AND COMPENSATORY TRAINING, MEAL PREPARATION, SAFETY PROCEDURES, AND INSTRUCTIONS IN USE OF ASSISTIVE TECHNOLOGY DEVICES/ADAPTIVE EQUIPMENT) DIRECT ONE-ON-ONE CONTACT BY PROVIDER, EACH 15 MINUTES COMMUNITY/WORK REINTEGRATION TRAINING (EG, SHOPPING, TRANSPORTATION, MONEY MANAGEMENT, AVOCATIONAL ACTIVITIES AND/OR WORK ENVIRONMENT/MODIFICATION ANALYSIS, WORK TASK ANALYSIS, USE OF ASSISTIVE TECHNOLOGY DEVICE/ADAPTIVE EQUIPTMENT), DIRECT ONE ON ONE CONTACT BY PROVIDER, EACH 15 MINUTES WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES ASSISTIVE TECHNOLOGY ASSESSMENT (EG, TO RESTORE, AUGMENT OR COMPENSATE FOR EXISTING FUNCTION, OPTIMIZE FUNCTIONAL TASKS AND/OR MAXIMIZE ENVIRONMENTAL ACCESSIBILITY), DIRECT ONE-ON-ONE CONTACT BY PROVIDER, WITH WRITTEN REPORT ORTHOTIC(S) MANAGEMENT AND TRAINING (INCLUDING ASSESSMENT AND FITTING WHEN NOT OTHERWISE REPORTED), UPPER EXTREMITY(S), LOWER EXTREMITY(S) AND/OR TRUNK, EACH 15 MINUTES PROSTHETIC TRAINING, UPPER AND/OR LOWER EXTREMITY(S), EACH 15 MINUTES CHECKOUT FOR ORTHOTIC/PROSTHETIC USE, ESTABLISHED PATIENT, EACH 15 MINUTES UNLISTED PHYSICAL MEDICINE/REHABILITATION SERVICE OR PROCEDURE 420 PHYSICAL THERAPY 421 VISIT CHARGE 422 HOURLY CHARGE 423 GROUP RATE 424 EVALUATION/RE-EVALUATION 429 OTHER 430 OCCUPATIONAL THERAPY 431 VISIT CHARGE 432 HOURLY CHARGE 433 GROUP RATE 434 EVALUATION/RE-EVALUATION 439 OTHER G0283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS, FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. Updated November