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Preferred Occupational Therapy

The Preferred Occupational Therapy (OT) Network was implemented January 1, 2001. Benefits are provided for medically necessary hand therapy services under Major Medical or other covered services. Specific group benefits and limitations continue to apply. Access "Find A Doctor" to locate a Preferred Occupational Therapist.

Covered Services
The Preferred OT Network specifically adds coverage for hand therapy and the treatment of lymphedema. Specific Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes commonly used by OTs treating hands are covered by this program. Special care should be given in reporting and documenting these services. 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; therefore, these services 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.

Non-Covered Services
Member contracts that do not have coverage for additional OT 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 Notification of Non-Covered Services 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.

Examples of Non-Covered Services:

Remember: Blue Cross and Blue Shield of Alabama does not provide benefits for professional services of an OT rendered to a member who is related to the OT by blood or marriage or who lives in the provider’s household.

Covered Providers

Note: Services should be billed using the supervising/Preferred OT's NPI.

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; therefore, services performed by these providers are not covered.

Filing for these kinds of services under the OT's NPI is not acceptable and is not reimbursable.

Several benefit plans require precertification for the first date of service. For these groups, this contractual requirement must be adhered to. Some groups require precertification as well as the initial evaluation order and goals for treatment prior to the first visit.

In addition, precertification is not required by Blue Cross and Blue Shield of Alabama for:

Specific contract requirements may be verified through ProviderAccess, your practice management software or by calling Provider Customer Service at 205-988-2213. Verification of benefits will assist in identifying members that do not require precertification or who may have have special benefits.

For all contracts that do not require precertification for the first date of service, or some other variation, precertification is required if the OT determines 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 Notification of 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 patient will be responsible for paying the service(s). There are no retroactive certifications on these contracts.

When filing a request for a precertification, submit the completed precertification form (including all dates of services in boxes) along with the documentation of evaluation and last five progress notes. If additional information is needed, you will be notified. Please make sure the required fields on the precertification form are complete. A determination can only be made if all required information is provided. Review decisions will be made within 72 hours of receipt of the required information and will be returned via facsimile or email and confirmed with a letter mailed upon completion of the review decision. Precertification request received after 2 p.m. will be considered as received the following business day.

Precertification requests should be faxed to:

Blue Cross and Blue Shield of Alabama
Fax Number: 205-402-9369
Attention: Occupational Therapy Precertification

For Primary Care Network (PCN), OT is considered a related service. Related services do not require a direct referral from the Primary Care Physician (PCP) to the OT. However, if occupational therapy is ordered by a physician other than the patient’s PCP, a valid referral from the PCP to the physician ordering the therapy must be received by Blue Cross. Remember, the Preferred Medical Doctor (PMD) contract requires PMDs to refer to preferred providers. By referring a member to a non-participating provider, the member will not receive in-network level benefits and will not be held harmless for any amounts not paid to the provider. Inpatient services provided at a Participating Hospital are considered at that in-network benefit level.

The number of visits per patient is defined as visits provided by the Preferred OT of the same group and/or tax identification per calendar year. For precertification purposes, Preferred OTs 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.

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 email with additional information to be included in the review. Notification of appeal results are made by telephone to the provider within 24 hours of receipt of the request followed with written notification.

Standard Appeal
A standard appeal is a formal request to review healthcare 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.

Appeal requests should be mailed or faxed 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 an OT and four visits are approved by Blue Cross and Blue Shield of Alabama, the OT 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 10 days of the decision using the telephone number provided on the non-certification letter. If the original peer reviewer is not available, a peer alternate will be available to discuss the case. This request does not count as an appeal.

Preferred Occupational Therapist Audits
A major strength of Blue Cross and Blue Shield of Alabama in managing healthcare costs is our ability to audit Preferred Providers and affect changes in utilization practice habits. Our contractual arrangements give us the right to audit Preferred Occupational Therapists' medical records in order to objectively evaluate 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 offsite 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 members 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 2014