Unit 3 Requirements for Physical Medicine, Occupational and Speech Therapy – Classic Traditional, Comprehensive and PPOBlue

Requirements The attending physician for therapy services should provide a physician’s for ClassicBlue order for an evaluation and therapy services as appropriate. Outpatient Traditional, therapy services must be medically necessary and appropriate. Providers will Comprehensive need to sufficiently document the patient’s file to support that the treatment and PPOBlue was medically necessary. If any audit or post-payment review by Highmark Blue Shield indicates that such a service was not medically necessary, payment can be retracted and the member held harmless.

Prior to performing therapy services, please be sure to confirm the eligibility of physical, occupational and speech benefits for the member. Eligibility and benefit inquiries regarding physical medicine, occupational and speech therapies can be obtained via NaviNet. If NaviNet is unavailable, please contact Highmark Blue Shield Facility Customer Service at, (866) 803-3708, option 4, during the hours of 8:00 a.m. through 4:30 p.m., Monday through Friday.

Network and Highmark Blue Shield products provide higher-level reimbursement for out-of-network services received from network providers and lower-level reimbursement for services services received outside the network. The specific percentages for network and out-of-network services are determined by the particular employer group contract.

Highmark Blue Shield Facility Manual for Care Management and Quality Improvement 3-1 Revised March 2006

Unit 3 Requirements for Physical Medicine, Occupational and Speech Therapy – DirectBlue

DirectBlue Although DirectBlue members are encouraged to select a primary care member choices physician (PCP), they are not required to select one. In order to receive the higher level of benefits, DirectBlue members must receive care from a network professional or institutional provider. Services provided by out-of- network professional and institutional providers may result in a lower level of benefits.

Care from The table below summarizes the procedure for obtaining therapy services network when the DirectBlue member chooses to receive treatment from a network therapy professional or institutional provider. providers Step Who does it What is done 1 DirectBlue Obtains an order from the attending physician for member therapy services. If the member has selected a PCP, the PCP may order the therapy services.

Selects and sees a network therapy provider. 2 Therapy provider Evaluates the member’s condition and determines plan of treatment. (Performing provider) Confirms eligibility of therapy benefits available to member, provides necessary services and communicates results of services rendered to the ordering physician.

Providers will need to sufficiently document the patient’s file to support that the treatment was medically necessary. Outpatient therapy services must be medically necessary and appropriate. If any audit or post-payment review by Highmark Blue Shield indicates that such a service was not medically necessary, payment can be retracted and the member held harmless.

Highmark Blue Shield Facility Manual for Care Management and Quality Improvement 3-2 Revised March 2006

Unit 3 Requirements for Physical Medicine, Occupational and Speech Therapy – SelectBlue

SelectBlue SelectBlue members have a number of choices to make when receiving member choices therapy treatments. They may choose to do any of the following:

• Choose a network professional or institutional therapy provider to receive a higher level of benefits. • Choose an out-of-network professional or institutional therapy provider, which may result in a lower level of benefits.

Care from The table below defines the process by which SelectBlue members access network physical, occupational or speech therapy from a network professional or therapy institutional provider. providers

Step Who does it What is done 1 SelectBlue member Obtains an order from the attending physician for therapy services. It is recommended that the member use their PCP to obtain the order for therapy services. However, the ordering provider may be a provider other than the PCP.

Selects and sees a network therapy provider. 2 Ordering provider Issues an order for an evaluation and appropriate treatment with the therapy provider. 3 Therapy provider Evaluates the member’s condition and determines plan of treatment. (Performing provider) Confirms therapy benefits available to members, provides necessary services and communicates the evaluation and treatment results back to the member’s ordering physician (and PCP).

Providers will need to sufficiently document the patient’s file to support that the treatment was medically necessary. Outpatient therapy services must be medically necessary and appropriate. If any audit or post-payment review by Highmark Blue Shield indicates that such a service was not medically necessary, payment can be retracted and member held harmless.

Highmark Blue Shield Facility Manual for Care Management and Quality Improvement 3-3 Revised March 2006