New Authorization Requirements for Outpatient Physical, Occupational, and Speech Therapy (Eff. 1/1/18)

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1 New Authorization Requirements for Outpatient Physical, Occupational, and Speech Therapy (Eff. 1/1/18) Effective January 1, 2018, Martin s Point Health Care will require providers to submit initial and extended prior authorization requests for all outpatient physical, occupational, and speech therapy. Authorization requests may be submitted electronically, using our online Authorization Request tool available at Using the online tool ensures the most timely receipt of your requests. You may also submit requests via fax to Martin s Point Health Care using the new Outpatient (PT/OT/ST) Therapy Authorization Request Form also available at the link above. Please fill out the new form completely, include all required clinical information, and fax to the number listed on the form to ensure the reviewer will have the information needed to complete the authorization in a timely manner. As a reminder, Martin s Point has 14 days to render a decision on all standard requests, 72 hours for all urgent requests (life-altering), and 24 hours on concurrent or extended requests. All authorization requests must be accompanied by required documentation supporting medical necessity (see list below.) If you have questions, feel free to contact us at AUTHORIZATION DETAILS Prior authorization requests must be submitted after the initial evaluation, but prior to the first treatment date. If the initial evaluation and first treatment occur on the same date, we will not deny payment (please indicate that on the prior authorization request form for appropriate claims adjudication). Therapy organizations must submit a prior authorization request and receive approval from Martin s Point prior to rendering the second session of therapy. Failure to have the approval will result in denial of payment for those and any subsequent unauthorized services. Prior authorization is required for any continued therapy after rendering all authorized initial visits. The therapy provider must request authorization online or submit another Outpatient (PT/OT/ST) Therapy Authorization Form indicating a request for authorization for Extension of Existing Therapy Services prior to the services being rendered. Clinical information, progress notes, detailed goal information, and plan of care must be faxed with the form and support the medical necessity for continuation of services.

2 Initial authorizations will be for a standard number of initial visits determined by the Apollo guidelines (see grid below) for each diagnosis/procedure. You will have a twomonth limit within which these initial visits may occur. The two-month timeframe allows for variances with start dates or adjustments to visit dates due to weather, vacations or other patient factors. Additional authorization requests for extended therapy will be required when: o The two-month time frame will expire before you have rendered all initially-authorized visits OR o All initially-authorized visits have been used (regardless of time frame) and more therapy is recommended REQUIRED DOCUMENTATION to accompany authorization requests: Initial Commencement of Therapy Authorization: o Completed Outpatient Authorization Form or online request form o Evaluation o Plan of care o Standardized Functional Assessments o First treatment note if provided on same day as evaluation Extended Visit or Habilitative Authorization: o Completed Outpatient Authorization Form (with ** section completed) o Evaluation (Initial and Re-evaluation if completed for Extended Visit Request) o Progress notes (daily and required updates) o Treatment notes/logs o Plan of care o Standardized Functional Assessments/Updates o Rationale for extended services INITIAL THERAPY AUTHORIZATION GUIDELINES: PHYSICAL / OCCUPATIONAL / SPEECH: Diagnosis Initial Authorization Visit Guidelines Total # Auth Visits after Evaluation / 2 Month Timeframe Spine Bulging/protruding discs 6 Compression fracture of vertebrae 6 Herniated discs 6 Low back pain 6

3 Neck pain/cervicalgia 6 Pain without radiculopathy 6 Scoliosis 6 Surgical Spine Fusion 8 Laminectomy 6 Upper Extremity (Non Surgical Shoulder) Adhesive capsulitis 6 Brachial plexus injury 6 Dislocation 6 Impingement 6 Rotator cuff tendinitis 6 Thoracic outlet syndrome 6 Surgical Shoulder Acromioplasty/impingement Release/subacromial decompression 8 Bankart procedure 12 Dislocations repeated open 6 Fracture closed 6 Fracture ORIF 6 Repair tendon rupture 8 Rotator cuff tear repair 12 SLAP (superior labral tear) 12 Total shoulder arthroplasty/replacement 12 Elbow Dislocation 6 Epicondylitis (medial/lateral) 8 Nerve compression/release 6 Other surgery 6 Status post fracture ORIF 12 Total elbow arthroplasty/replacement 10

4 Wrist/Hand Carpal tunnel release/syndrome 6 DeQuervain's (tenosynovitis) 6 Fracture ORIF 8 Joint replacement 8 Lower Extremity Pelvis/Hip Hip fracture 6 Pelvis fracture 6 Piriformis syndrome (sciatic nerve lesion) 6 Tendinitis 6 Total hip arthroplasty/replacement 12 Non Surgical Knee/Thigh/Leg Chondromalacia 6 Dislocation/subluxation 6 Fracture 10 Pain 6 Sprain 6 Strain 6 Surgical Knee Anterior cruciate ligament repair 8 Medial collateral ligament repair 8 Fracture ORIF 10 Other open procedure 6 Patellar fracture 8 Posterior cruciate ligament repair 8 Total knee arthroplasty 10 Non Surgical Ankle Fracture 6 Tendinitis 6 Tenosynovitis 6

5 Surgical Ankle Achilles tendon repair 8 Fracture ORIF 6 Ligament reconstruction 12 Other open procedure 6 Non Surgical Foot Capsulitis 6 Metatarsalgia 6 Tarsal tunnel syndrome 6 Tendinitis 6 Tenosynovitis 6 Surgical Foot Other open procedure 6 Tarsal tunnel release 6 Speech Amyotrophic lateral sclerosis (ALS) 12 Cerebrovascular accident (CVA) Late 12 Cerebrovascular accident (CVA ) New 12 Parkinson's disease 12 Other Amputation 8 Amyotrophic lateral sclerosis (ALS) 12 Burns 12 Cerebrovascular accident (CVA) Late 12 Cerebrovascular accident (CVA ) New 12 CRPS/Complex regional pain syndrome 10 Dizziness and giddiness 6 Fibromyalgia 6 General muscle pain 6 Headache 6 Lymphedema 10 Multiple Sclerosis 12 Osteoarthritis/degenerative joint disease 6 Paralysis related to surgery 8 Parkinson's disease 12 Rheumatoid arthritis 6

6 Other RSD/Reflex sympathetic dystrophy syndrome 10 Urinary incontinence 6 Vertigo 8 Weakness 6