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Effective January 1, 2001, the Preferred Occupational Therapy Network was created. Benefits are provided for medically necessary hand therapy services under Major Medical or Other Covered Services. Specific group benefits and limitations continue to apply. Click here to locate a Preferred Occupational Therapy providers.
Standard Appeal – A standard appeal is a formal request to review health care services already provided and not certified as medically necessary for the benefit coverage. It may be initiated by telephone, facsimile or mail by the member, attending physician or other ordering provider, or the facility rendering the service. A peer reviewer not involved in the original non-certification decision will review the appeal. The necessary medical record will be required for review if not submitted previously to Blue Cross and Blue Shield of Alabama. The member, attending physician or other ordering provider, and claims administrator will be notified in writing of the appeal determination by no later than 30 days after receiving the required documentation to conduct the appeal review.
The Preferred Occupational Therapy Network specifically adds coverage for hand therapy and the treatment of lymphedema. There are certain procedure codes and diagnosis that will be covered by this program. For occupational hand therapy to be medically necessary, it must be reasonable and necessary for the member’s diagnosis or the treatment of the member’s condition. Medical necessity is indicated when:
Services such as the application of hot and cold packs, use of exercise equipment, and repetitive exercises do not ordinarily require the skills and full attention of a qualified occupational therapist, and therefore are not separately billable. If such treatments are given as a prerequisite to a skilled occupational therapy procedure, they are considered part of that modality and are not separately billable.
Following are the procedure codes covered under the Preferred Occupational Hand Therapy Network. Special care should be given in reporting and documenting these services.
95832 Muscle testing of the hand
95852 Range of motion of hand
97003 Occupational therapy evaluation
97004 Occupational therapy re-evaluation
97014 Electrical stimulation, unattended
97016 Vasopneumatic devices
97018 Paraffin bath
97022 Whirlpool (includes fluidotherapy)
97032 Electrical stimulation, attended
97034 Contrast baths
97110 Therapeutic procedure (exercise)
97112 Neuromuscular reeducation
97140 Manual therapy techniques
97504 Orthotics fitting and training
97530 Therapeutic activities
97535 Self-care/home management (ADL) training
97601 Removal of devitalized tissue from wound(s) selective debridement
97602 Removal of devitalized tissue from wound(s) non-selective debridement
97703 Checkout for orthotic/prosthetic uses
97755 Assistive technology assessment, each 15 minutes
337.21 Reflex sympathetic dystrophy, specific to hand 816.10-816.13 Open fracture of one or more phalanges of hand
354.0 Carpal tunnel syndrome 817.0-817.1 Multiple fractures of hand bones, open or closed
354.2 Mononeuritis, lesion of ulnar nerve specific to hand 833.00-833.19 Dislocation of wrist
354.3 Lesion of radial nerve 834.00-834.02 Closed dislocation of finger
457.0 Post mastectomy lymphedema syndrome 834.10-834.12 Open dislocation of finger
457.1 Other lymphedema 842.00-842.09 Sprain and strain, wrist
712.14-712.94 Crystal arthropathies 842.10-842.19 Sprain and strain, hand
714.0-714.9 Rheumatoid arthritis, forearm 881.12 Complicated open wound, wrist
715.04-715.94 Osteoarthrosis 881.22 Complicated open wound with tendon involvements, wrist
716.04-716.94 Other and unspecified arthropathies 882.1-882.2 Open wound of hand, complicated, with tendon involvement, except fingers
718.04-718.94 Other derangement of joint 883.1-883.2 Open wound of fingers, complicated, with tendon involvement
719.04-719.64 Other and unspecified disorders of the joints 884.0-884.2 Multiple and unspecified open wound of upper limb, with or without complication, with tendon involvement
719.84-719.94 Other and unspecified disorder of the joints 885.0-885.1 Traumatic amputation of thumb
727.00 Tenosynovitis and synovitis, specific to hand 886.0-886.1 Traumatic amputation of other finger(s)
727.03 Tenosynovitis and synovitis, trigger finger 887.0-887.7 Traumatic amputation of arm and hand
727.05 Other tenosynovitis and synovitis of the hand and wrist 923.20 Contusion of hand(s)
728.6 Contracture of palmar fascia 927.20 Crushing injury to wrist and hand(s) except finger(s) alone
736.1 Mallet finger 927.3 Cushing injury to finger(s)
813.00-813.82 Fracture of radius and ulna 944.00-944.58 Burns of wrist(s) and hand(s)
814.00-814.09 Closed fractures of carpal bone(s) 955.1 Injury to peripheral nerve, median with hand involvement
814.10-814.19 Open fracture of carpal bone(s) 955.2 Injury to peripheral nerve, ulnar with hand involvement 815.00-815.09 Closed fracture of metacarpal bone(s) 955.3 Injury to peripheral nerve, radial with hand involvement
815.10-815.19 Open fracture of metacarpal bone(s) 955.6 Injury to peripheral nerve, digital with hand involvement
816.00-816.03 Closed fracture of one or more phalanges or hand
Member contracts that do not have coverage for additional occupational therapy services will have no coverage for services other than hand therapy. Preferred Occupational Therapists are responsible for notifying the patient of services that are not medically necessary for the treatment of his/her condition or are not covered. Within this manual is a sample non-covered statement that can be used to explain to the member that he/she is responsible for these charges. The member should sign the statement prior to services being rendered.
Example of Non-Covered Services:
Remember: Blue Cross and Blue Shield of Alabama does not provide benefits for professional services of an occupational therapist rendered to a member who is related to the occupational therapist by blood or marriage or who lives in the provider’s household.
Note: Services should be billed using the supervising/Preferred Occupational Therapist’s provider number.
Non-Covered Providers of Occupational Therapy Services
Athletic trainers, exercise physiologists, massage therapist, RNs, LPNs certified strength trainers, secretaries, and office personnel are not considered covered providers. Services performed by these providers are not covered.
Filing for these kinds of services under the occupational therapist provider number is not acceptable and is not reimbursable.
Several benefit plans require precertification from the first date of service. For these groups, this contractual requirement must be adhered to. The following groups require precertification along with initial evaluation, order, and goals for treatment prior to the first visit:
In addition, precertification is not required for:
Specific contract requirements may be verified by e-Practice Management (InfoSolutions®) or by calling Provider Customer Service at 205 988-2213. Verification of benefits will assist in identifying subscribers that do not require precertification or whose benefits are different.
For all contracts that do not require precertification from the first date of service, or some other variation, precertification is required if the occupational therapist feels that the member’s care will require more than 15 visits. Requests for precertification should be submitted after the 14th visit. If precertification is not obtained, all services associated with the 16th and subsequent visits will be non-covered 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). Patients may be billed if they have signed a Non-covered Services Statement for each visit indicating that they have been properly informed that the services to be rendered are not covered by Blue Cross and that the patients will be responsible for paying the services. There are no retroactive certifications on these contracts.
When filing a request for a precertification only submit the precertification form. If additional clinical information is required, you will be notified. Do not send additional information unless requested to do so.
The precertification request should be submitted to:
Blue Cross and Blue Shield of Alabama
Fax Number: 205 220-9133
Attention: Occupational Therapy Precertification
For Primary Care Network (PCN), occupational therapy (OT) is considered a related service. Related services do not require a direct referral from the Primary Care Physician (PCP) to the occupational therapist. However, if OT is ordered by a physician other than the patient’s PCP, a valid referral from the PCP to the physician ordering the OT must be shown on the Blue Cross and Blue Shield system. If a physician other than the patient’s PCP orders OT, a referral is required to the ordering physician. Remember that the Preferred Medical Doctor (PMD) contract requires PMD physicians to refer to preferred providers. By referring a member to a non-participating provider, the member will not receive in-network level of benefits and will not be held harmless from any amounts not paid to the provider. (Inpatient) Services provided at a participating hospital will be considered at that in-network benefit level.
The number of visits per patient is defined as visits provided by the Preferred Occupational Therapist of the same group and/or tax identification per calendar year. For precertification purposes, Preferred Occupational Therapists are only responsible for the therapy provided by their group and/or tax identification.
Note: A current physician referral must be maintained in the patient’s medical record.
Click here for a precertification form. If the required fields on the precertification form are not complete, a determination cannot be made. Review decisions will be made within one business day of receipt of the required information and will be returned via facsimile or e-mail and confirmed with a letter mailed within 24 hours of the review decision. Precertification request received after 2:00 p.m. will be considered as received the following business day.
Patients should be discharged when:
Appeals of Determination Not to Precertify
One appeal, either expedited or standard, may be performed for medical necessity non-certification determinations.
Expedited Appeal – An expedited appeal is available when there is an imminent or ongoing service requiring additional review of a non-certification determination. Appeal by telephone, facsimile, or e-mail with additional information to be included in the review. Notification of the results of the appeal will be made by telephone to the provider within 24 hours of receipt of the request with written notification to follow.
Standard Appeal – Requests for standard appeal or a decision not to certify additional visits must be made in writing by mail or facsimile by the provider and include the medical records needed for the review if not submitted previously to Blue Cross and Blue Shield of Alabama.
Appeal requests should be mailed to:
Blue Cross and Blue Shield of Alabama
Post Office Box 362025
Birmingham, Alabama 35236
Fax Number - 205 402-9369
Telephone number for expedited appeals - 205 220-6356 or 205 220-7202
When requesting an appeal, additional information to support the medical necessity of the requested visits should be included. Appeals should not be requested until covered visits are used. Appeals can only be requested when no additional treatments have been confirmed. There are not appeals of partial confirmation or approvals. For instance, if eight additional visits are requested by a Preferred Physical Therapist and four visits are approved by Blue Cross and Blue Shield of Alabama, the physical therapist may not request additional visits if he/she determines additional treatment is necessary.When a non-certification decision is made without a physician conversation, a peer to peer conversation may be requested within 72 hours of the decision using the telephone number provided on the noncertification letter. If the original peer reviewer is not available, a peer alternate is available to discuss the case. This does not count as an appeal. Any request beyond 72 hours of the decision is considered an appeal.
Preferred Occupational Therapist Audits
A major strength of Blue Cross and Blue Shield of Alabama in managing health care costs is our ability
to audit Preferred Providers and effect changes in utilization practice habits. Our contractual arrangements give us the right to audit medical records of patients of Preferred Occupational Therapists in order to objectively evaluate the coding, billing, and practice patterns, as well as the completeness of their medical records.
An audit can be triggered by external referrals from members, group administrators, anonymous tips, and even other occupational therapists that feel that a particular occupational therapist, group or facility is not in compliance with the program guidelines. An audit may be triggered from internal claims and precertification data also.
If an off-site audit reveals unusual practice patterns or billing procedures that result in overpayments, refunds are required from the occupational therapist and the amount is returned to the groups whose subscribers were affected by the incorrect practices. Any occupational therapist having an unsatisfactory audit must immediately correct any problems. A follow up audit is performed to ensure that he/she is in compliance with the Preferred Occupational Therapist guidelines. A second unsatisfactory audit can result in the therapist being removed from the Preferred Occupational Therapy Program.
Last Updated November 2007