Physical Medicine Management

Effective May 1, 2024, New York providers will be required to request prior authorization for outpatient physical medicine and home health services for members.

The change includes the following outpatient services (see the table below for more information):

  • Physical therapy (PT)*
  • Occupational therapy (OT)*
  • Chiropractic (Chiro)*
  • Home health (HH)**
Outpatient Service(s) Applicable Members and Exclusions
Physical therapy, occupational therapy, and chiropractic

This prior authorization change applies to members in Commercial plans.

*ASO, FEP, and Medicare Advantage are excluded from the prior authorization requirement.

Home health

This prior authorization change applies to members in Commercial plans and ASO groups.

**Medicare Advantage is excluded from the prior authorization requirement; FEP prior authorization is not required for initial visits, per the plan limit. If a member needs additional visits (beyond the plan limit), then prior authorization is required.

 

We have a number of resources available to assist providers with the change and the electronic authorization process for these outpatient services. 

 

Provider Communication

Western New York

 Northeastern New York

 

Instructional Videos

Click the links below to view the videos which walk you through the authorization process in Availity. If you experience an issue, please refresh your browser. If the issue persists, contact resourcecenter@email.highmark.com.

Prior Authorization

Extension Request

 

Authorization Requirements

For additional information and resources on submitting authorizationsCLICK HERE.


What is Helion?

Helion is a health care technology and services company that helps payers cultivate high-performing networks while empowering providers to operate at their best — and in doing so, help patients heal better.

You can learn more about Helion here.

Last updated on 3/27/2024 1:59:38 PM

 

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