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Changes to physical therapy and occupational therapy precertification requirements for Medicare Advantage members now in effect

January 15, 2020

As previously communicated in a Partners in Health UpdateSM article, as of January 1, 2020, providers must to adhere to the following changes to physical therapy (PT) and occupational therapy (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, PT/OT 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: PT/OT 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:

    • 97161
    • 97162
    • 97163
    • 97165
    • 97166
    • 97167

    Re-evaluation:

    • 97164
    • 97168

Notification/precertification process information

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As of January 1, 2020, notifications must be made to the Utilization Management department by calling 1-800-ASK-BLUE (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.

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.


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