Outpatient Rehabilitative Therapy Services Prior Authorization Policy (PM) Form

Outpatient Rehabilitative Therapies

(including Physical Therapy, Occupational Therapy, and Speech/Language Therapy services rendered by clinicians licensed to perform these therapies) are intended to restore (or move a patient toward) functional capabilities that were present prior to disease or injury, or to improve functional capabilities for members with significant functional impairment secondary to congenital anomalies.

Harvard Pilgrim covers Outpatient Rehabilitative Therapies (i.e., Physical, Occupational, or Speech/Language Therapy):

• Authorization is not required for the initial evaluation.
• After the initial evaluation (prior to initiating treatment services), authorization is required for all outpatient rehabilitative therapy services when the member has a "Per Condition" limit. Please see Outpatient Rehabilitative Therapies Prior Authorization Request Form for more information. Note: In specific situations, additional documentation may be required for approval of treatment.
• Authorization is required for additional services beyond those approved at the time of the initial authorization.
• Authorization is not required when the member has a "Per Visit" limit (plan with a limited number of visits for outpatient rehabilitative therapy).
• Outpatient treatment is covered within applicable benefit limits for eligible members if there is a reasonable expectation of significant functional improvement.

Criteria

• Covered services are subject to applicable copayments, coinsurance, deductibles, and benefit limitations.
• The member must be eligible for coverage at the time the service is rendered, and not have previously exhausted available benefits for the condition.
• Requested services must, in the judgment of the member’s PCP or attending physician, be reasonably expected to improve the member’s functional ability to perform activities of daily living.
• The member must be physically able and cognitively willing to attend outpatient therapy sessions, and compliant with the plan of care including keeping appointments and performance of their home exercise program.
• The treatment plan proposed by the therapist must be approved by the ordering physician (in accordance with state regulations) and include measurable functional goals.

Excluded Services

The following services are excluded from coverage:

• Avocational performance enhancement services (e.g., for dancers or runners)
• Biofeedback that is not a component of a medically necessary rehabilitative therapy program
• Ongoing cognitive therapy for progressive degenerative conditions
• Driving evaluation/re-evaluation
• Educational services/testing and school performance tests (e.g., SIPT, praxis testing)
• Experimental services (e.g., auditory integration therapy, facilitative communication)
• Learning disabilities services (e.g., ADD, ADHD)
• Massage therapy that is not performed by a licensed physical therapist or occupational therapist as a component of a medically necessary skilled rehabilitative therapy program
• Speech treatments for central auditory processing or voice therapy without structural abnormality (Massachusetts mandate supersedes benefit caps)
• Vocational rehabilitation, testing and screening (e.g., work hardening, work site evaluations and functional capacity evaluations)
• Rehabilitative services provided in the home setting (unless the provider is a contracted home health care agency)

Action Required

Notification by the servicing provider (i.e., hospital or therapist) is required up to the date of service (or no later than the next business day if after hours).

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL
D.9
January 2018
Harvard Pilgrim Health Care a Point32Health company
Referral, Notification, and Authorization-Authorization

Communicate Outpatient Rehabilitative Therapies Service Requests

Communicate outpatient rehabilitative therapies service requests through one of the following channels.

Electronic

• Submit a transaction record with required information using HPHConnect or NEHEN transaction service.
  • Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at HPHConnect/User Guides.)
  • For NEHEN instructions, refer to your NEHEN documentation.

Harvard Pilgrim Response

An immediate confirmation is available online. Services that require benefit eligibility review and/or prior authorization will pend for review.

Fax

Fax a completed an Outpatient Rehabilitative Therapy Services Notification and Authorization Form to Harvard Pilgrim's Referral/Authorization Team.

• Fax: HMO, POS, PPO –– 800-232-0816

Harvard Pilgrim will create a transaction within 2 business days. Providers may check the status of submitted authorization requests using the electronic channels noted above.

Information Required

The following information is required for notification of outpatient rehabilitative therapy:

• Member's name and Harvard Pilgrim identification number
• Provider's name and National Provider Identifier (NPI)
• Servicing provider's phone and fax numbers
• Service requested (i.e., PT, OT, ST, etc.)
• Diagnosis and clinical information (i.e., right side/left side, if applicable)
• Prescription information (as part of the medical record)
• Details of any recent surgeries to the injured body part that may entitle the patient to additional covered services

Notification Changes

Harvard Pilgrim must be notified when any change to the original notification occurs, such as a change in the confirmed start of care date, date of service or extension of service beyond the confirmed span.

Electronic

Submit a new transaction record using HPHConnect or NEHEN transaction service.

• Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at HPHConnect/User Guides.)
• For NEHEN instructions, refer to your NEHEN documentation.

Fax

Fax a completed a Rehabilitative Therapies Service Request Form to Harvard Pilgrim's Rehabilitative Therapy Team.

• Fax: 617-509-1528

Additional Therapy

To request additional visits beyond those initially approved, authorization is required. To request authorization, please enter the request through HPHConnect or NEHEN as noted above and complete the Outpatient Rehabilitative Therapy Services Notification and Authorization Form and fax it to 800-232-0816.

Once a member's benefit limit is exhausted, additional rehabilitative therapy services are not covered. If services are continued beyond the individual member's Harvard Pilgrim benefit limit, Harvard Pilgrim will deny claims for visits beyond the benefit limit and the member will be financially responsible for payment for non-covered services.

Contact Information

Contact the Referral/Authorization Team at 800-708-4414, option 7.

PUBLICATION HISTORY

01/01/12 removed First Seniority Freedom information from header
05/15/14 changed document title from "Outpatient Functional Therapy Notification" to "Rehabilitative Therapies"; amended overview section
08/15/14 added home rehabilitative services information to excluded services
03/15/15 changed prior auth required for all outpatient rehabilitative therapy services beyond the initial visits from 15 to 25 visits approved by the PCP or attending physician; made administrative edits for clarity
07/15/15 clarification of notification and authorization requirements and process for requesting additional services
01/01/18 updated authorization requirements