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MA PAP 309

Outpatient Therapy Prior Authorizations


Provider Administrative Policy

Section
Prior Authorizations
Policy Date
December 2011
Status/Date
Revised/ January 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Outpatient Therapy Prior Authorizations

Blue Cross of Idaho manages outpatient therapy services for physical therapy (PT), occupational therapy (OT) and speech therapy (ST).

Prior to December 31, 2012, we initially authorized twelve (12) visits including the evaluation when requested by a contracting provider or by a non-contracting, Medicare participating provider for Secure Blue PPO members. After the initial 12 visits, we limited the number of subsequent visits to six visits per request.

Beginning January 1, 2013:

  • The initial therapy requests will be approved for a 60-day timeframe without limiting the number of visits when requested by a contracting provider or by a non-contracting, Medicare participating provider for Secure Blue PPO members.
  • Additional and subsequent therapy requests beyond the initial 60-day timeframe will be reviewed and approved on a 30-day basis.
  • Clinical information needed to support the review of additional visits must include initial evaluation, goals and measurable progress report (degrees/percentage/level of function/measurements, etc.).

DOCUMENTATION REQUIRED:  Initial Therapy Request:

Additional Therapy Request

  • Medicare Advantage Prior Authorization Request Form
  • Therapist's initial evaluation with measurable goals
    • Example:
      Goal:  Right knee AROM to 0-120 deg
      Initial Evaluation:  Right knee AROM 0-90 deg
  • Measurable progress toward the initial goals
    • Example:
      Measurable Progress (date):  Right knee AROM 100 deg

Subsequent Therapy Request

Submitting Outpatient Therapy Requests:

  • Submit requests online at bcidaho.com. Or see MAPAP300 or MAPAP301 if online access is not available.
  • Fax requests to the number listed on Medicare Advantage Prior Authorization and CMS guidelines. See MAPAP102 for contact information.

Sample Documentation Guidelines for Outpatient Therapy

Documentation should be legible and reflect progression of the member's response to therapy. The initial evaluation, plan of care, progress notes and discharge notes should include the following information:

Initial therapy evaluation/plan:

  • Diagnosis and onset date
  • Name of physician, date last seen by physician and next physician appointment, if applicable
  • Reason for referral
  • Patient's complaint
  • Past medical history
  • Any previous or current therapy
  • Current and past functional abilities
  • Patient's cognitive status (ability to learn)
  • Home/work environment
  • Spouse/family/caregiver ability to help if needed
  • Pain scale (Example 0 to 10)
  • Patient/family goals
  • Objective measurements or testing results may include but are not limited to communication skills, range of motion, strength, balance, coordination, functional mobility and gait
  • Short and long term goals must be functional, measurable and appropriate for the diagnosis with documented time parameters
  • Treatment plan

Subsequent Care Plan:
Provide outpatient therapy treatment in accordance with an ongoing, written plan of care, completed by the therapist.

The care plan should be appropriate for the diagnosis, presenting symptoms and findings or the initial therapy evaluation. Do not use the term "indefinite" as an estimate of duration.

The care plan should include:

  • Specific, measurable long and short term goals
  • A reasonable estimate of when the goals should be reached
  • The specific modalities and/or therapeutic procedures to be used in treatment
  • The frequency and duration of treatment

The care plan should be modified/revised in the progress notes as the patient's condition changes.

Progress Notes:

  • Patient's current condition/complaints
  • Documentation supporting the specific skilled therapy intervention performed
  • Patient's response to the therapy
  • Measurable progress towards goals
  • Objective measurements
  • Patient adherence to recommendations from therapy personnel
  • Evidence of instruction on home exercise program and patient's compliance
  • Change in therapy care plan if needed
  • Plan for further therapy

Policy History

Date Action Reason
January 2013 Revised Removed language regarding 12 visits

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