This FAQ was revised on September 3, 2019.

These frequently asked questions (FAQs) were developed to answer questions about the Independence Blue Cross (Independence) new claim payment policies that change reimbursement for multiple therapies for outpatient facility providers, specifically to include physical, occupational, and speech therapy services.

This document will be updated as additional information becomes available.

1. What changes is Independence making to its claim payment policies for multiple therapies?

Independence will implement new claim payment policies for multiple therapies for outpatient facility providers, specifically to include physical, occupational, and speech therapy services. These claim payment policies will apply to specific CPT^® and HCPCS codes designated by the Centers for Medicare & Medicaid Services (CMS) as “Always Therapy” for these services. Independence will include full payment for the procedure with the highest total allowance and reduced payment for each subsequent procedure provided by the same provider, for the same member, on the same date of service.    

2. What is the effective date of the new claim payment policies for multiple therapies? (Revised 9/3/2018)

The following policies were posted to our Medical Policy Portal as Notifications on August 1, 2019, and went into effect September 1, 2019:

• Commercial: #00.01.68: Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
• Medicare Advantage: #MA00.050: Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services

3. What CPT and HCPCS codes are included in these policies?

The CPT and HCPCS codes that are included in these policies are listed in Attachments A of the policies.

4. Are any services exempt from the changes to the claim payment policies for multiple therapies?

Yes. Services conducted in an inpatient facility are not included in these claim payment policies. 

5. How will claims with multiple procedures be processed?

Facility outpatient therapy claims, when multiple physical, occupational, and speech therapy services designated as “Always Therapy” are reported by the same provider, for the same member, on the same date of service will be processed as follows:

• The procedure code with the highest total allowance is eligible for reimbursement at
  100 percent of the provider's applicable contracted rate.
• Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

In addition, multiple procedures may be submitted on one claim or on multiple claims. These claim payment policies for services designated as “Always Therapy” are based on the date of service regardless of the date the claim was submitted or received.

6. Who will be affected by the new claim payment policies for multiple therapies?

The changes affect Independence-participating outpatient facility providers performing multiple therapies. The changes to these policies affect the following products:

• Commercial (fully insured and self-funded): HMO, POS, EPO, and PPO
• Medicare Advantage: HMO, POS, and PPO

7. Can I dispute the reimbursement rate I received based on the claim payment policies for multiple therapies?

These are claim payment policies and assumes services have been documented and billed in a manner that is consistent with applicable coding guidelines. Notice of these claim payment polices were provided in accordance with the terms of our provider contracts. As a participating provider, you agree to comply with changes that may be made by Independence to claim payment and other policies from time to time. Therefore, changes to these claim payment policies are not eligible for dispute, review, or appeal. However, if you think that the reimbursement reduction applied under these policies is not in accordance with your applicable contracted rate, you may follow the dispute resolution process in your provider agreement.     

8. How will I know if I have a claim that is affected by these claim payment policies?

Claims affected by these claim payment policies for multiple therapies will appear on your electronic remittance report (835) and/or paper Provider Remittance with a CO59 code.

9. How have providers been notified of the changes to these claim payment policies for multiple therapies? (Revised 9/3/2018)

• On August 1, 2019, policy changes were announced to providers via:
  • Medical Policy Portal;
  • Partners in Health Update^SM, our online provider newsletter;
  • Independence NaviNet^® web portal (NaviNet Open) Plan Central in a message containing a summary of the changes to the policies and a link to the Medical Policy 
• On August 6, 2019, a Provider Bulletin was also sent to facilities as a notification of these new policies.
• On September 3, 2019, providers were reminded of the new policies via:
  • Partners in Health Update
  • Independence NaviNet Open Plan Central

For more information

Please refer to the Medical Policy Portal to view the most recent version of the policies, as they will supersede the information in this FAQ.

If you cannot find the information you are looking for here and have further questions, please call 1-800-ASK-BLUE. 

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