PA Resources Portlet
CODING & DOCUMENTATION
EDUCATION & EVENTS
ENROLLMENT & CREDENTIALING
FORMS & MANUALS
POLICIES & GUIDELINES
PROGRAMS & INITIATIVES
PROVIDER NETWORKS & SPECIALTIES
PA Dynamic Rendering
Therapy - Occupational, Physical, Speech
Therapy services may require precertification for your Blue Cross patients, including those with Blue Advantage plans. To see if precertification is needed for a patient, check eligibility and benefits through ProviderAccess or your practice management system.
To request precertification of therapy services, complete the appropriate form below and fax to the number given on the form.
Precertification Steps and Criteria
Checking eligibility and benefits through ProviderAccess or your practice management software provides the patient's current eligibility status for therapy services. To check via ProviderAccess, follow these steps:
- Choose the appropriate service from the "Service Type" drop-down menu, enter a date of service, and click "Update Result."
- When the benefits display, select the Limitations tab.
- See the number of allowed visits and the number of remaining visits. (Remaining visits will be the number of therapy visits received through you or any other provider.)
Once benefits are verified, use the forms below to obtain precertification for services. These forms must be filled out completely and be accompanied by all required information, as noted on the forms. This includes:
- Copy of initial evaluation
- Current plan of care
- Last five treatment notes/exercise flow sheets
- Physician's prescription with medical diagnosis (on physician's letterhead or prescription pad)
- Current reassessment with objective findings, updated goals, measurable data for all goals (baseline and current), progress toward goals, current treatment plan that includes frequency/duration performed at 15th visit, functional communication skills, and indication of whether a home program is being used
- Number of visits requested for this certification
- Projected end date of therapy
- Justification for continuation of therapy
While providers should always check eligibility and benefits prior to providing services, here are some general benefit guidelines to keep in mind:
- Many Blue Cross plans do not require precertification for initial visits, such as the first 15 visits. However, precertification is required if the therapist determines that the patient’s care will require more than this allowed number of visits with no precertification.
- Submit precertification requests before the final visit within the allowed number of visits. For example, if the patient has a limit of 15 visits, obtain precertification for additional visits before the 15th visit. If precertification is not obtained, all services associated with the 16th and subsequent visits will be noncovered, and the patient will be held harmless (with the exception of a new evaluation for a new episode of care and the services performed on the date of such initial evaluation). Only a small number of benefit plans allow retroactive certifications.
- Bill patients if they have signed a Notification of Non-Covered Services statement for each visit indicating that they have been properly informed that services to be rendered are not covered by Blue Cross and the patient will be responsible for paying the service(s).
Fax precertification forms to the fax number indicated at the top of the forms.
Pre-Service Appeals – Call 1-205-220-7202. See our Pre-Service Appeals and Concurrent Appeal Process Q&A for more information. For additional information on appeals, visit our Provider Appeal webpage.
Precertification for Services Related to Autism
Documentation needed for an autism review includes:
- The initial written evaluation.
- A six-month plan of care.
- The evaluation report that reflects the patient's autism diagnosis, i.e. psychological evaluation.
- The physician's prescription with medical diagnosis (on physician's letterhead or prescription pad).
- A progress report and/or plan of care (if treatment has been ongoing) that includes measurable data for all goals (baseline and current), functional communication skills, new goals, and indication of whether a home program is being used.
- A psychological report confirming that autism testing was performed by a mental health professional.
Several benefit plans require precertification for the first date of service. For these groups, this contractual requirement must be adhered to. Some groups also require the initial evaluation order and goals for treatment prior to the first visit.