PT/OT FAQs for Providers

Benefits

How can I view member benefits?

Prevea360 Health Plan recommends checking member eligibility via the Provider Portal, but providers can also call Prevea360Health Plan Customer Service to check.

Is there any program with NIA Magellan for Speech Therapy?

No, Speech Therapy authorizations will continue to come to Prevea360 Health Plan. Continue to use your current process.

Submitting requests

What is NIA Magellan’s typical turnaround time for prior authorization?

The average turnaround time is 2-3 business days after all clinical documentation has been received. NIA Magellan has 14 business days to make a determination, but the average is 2-3 business days.

How often is member information updated in NIA Magellan’s system?

Prevea360 Health Plan has a daily data file exchange with NIA Magellan. Member information is updated each day.

Does it have to be a clinical person starting the request?

Either the physical therapist or office staff can complete authorizations. Use the NIA Magellan checklist located on RadMD to ensure you have all relevant information before starting the authorization request.

Does each person submitting authorization requests need their own personal login to NIA Magellan?

Yes, each person submitting authorization requests needs their own login and password per HIPAA regulation.

When placing the request on RadMD or through the Customer Service, do I need the individual therapist name?

No, you only need to provide the group name.

How many days will providers have to submit authorization?

Providers have 10 days from evaluation date to submit for both care registration and authorization. No exceptions will be made.

Visits

Do members have eight care registration visits for both PT and OT?

Members have eight total care registration visits per calendar year, regardless of service type. All additional visits require authorization.

Do the members start with a new PT/OT benefit starting 1/1/2016?

No, PT/OT benefit counters renew when the insurance policy renews. Therefore, it is important to first check the member’s benefits prior to submitting the authorization request. For example, some of our members’ policies renew in July, therefore all of their benefit counters reset on their policy renewal date in July. This differs from care registration, as care registration resets on Jan. 1 for all members.

If a patient has two PT visits in one day, is this counted as one or two visits in their benefit count?

If the patient has two PT visits in one day by the same provider (i.e. same billing information), Prevea360 Health Plan counts this as one visit in the member’s benefit count. If the services differ, for example if the patient has one PT visit and one OT visit on the same day, this would count as two separate visits in the member’s benefit count.

If we are seeing a patient in December, do we have to submit a new authorization request for services in January?

All authorizations are end dated for Dec. 31, so the provider would need to login to NIA Magellan to complete a care registration for services on and after Jan. 1 of the next calendar year.

Do I have to do the authorization before the evaluation? If we don't do the eight visits, do we still get paid for the evaluation?

Providers do not have to do the authorization until after the evaluation is completed. If there are no follow-ups after the evaluation, the provider will be paid for the evaluation.

Can providers perform PT/OT treatment on the same day as the evaluation?

If providers choose to provide PT/OT treatment on the same day as the evaluation without receiving an approved authorization first, it is not guaranteed that the services will be covered by Prevea360 Health Plan. It is always recommended that providers first receive the approved authorization before performing treatment.
Again, if the therapy is found to not be medically necessary, then the therapy would not be covered, but the evaluation would be covered.

Do I need to call the 800 number to change information on the authorization?

Yes, you will need to call NIA Magellan’s Customer Service number if you need to update/change a current authorization. If it is a new episode of care, a new authorization needs to be submitted.

When care registration visits have been used and additional visits are needed, can I obtain approval for additional visits on the same day the services will be provided?

Services will need to have prior authorization; if providers provide services without an authorization and the authorization is denied, Prevea360 Health Plan will not cover those services.
Again, if additional visits are needed, please call NIA Magellan’s Customer Service number. NIA Magellan may request clinical documentation to support the need for additional visits.

What happens if a patient has remaining visits after the validity period ends?

If the validity period is ending and the patient hasn’t used all of their visits, the provider will need to call NIA Magellan’s Customer Service number to extend the validity period.

For each authorization, is it expected that we upload more clinical documentation after the initial eight visits? And requesting more visits?

Yes, we ask you to provide the evaluation notes and progress notes if you are requesting more than the eight visits.

If a member needs to go to two different locations for treatment, do we need two different authorizations?

If both providers are part of the same group and submit claims with the same billing information, a separate authorization is not necessary.

If a current patient comes in with a new diagnosis (episode of care), is an additional authorization required?

If a patient has an additional diagnosis that includes a separate body region from their authorization, an additional authorization is required.

Do you allow Licensed Athletic Trainers (LATs) to perform physical therapy services?

Prevea360 Health Plan’s guideline on LATs has not changed. If you have specific questions about how you use LATs or would like a copy of our policy on the use of LATs, reach out to your Provider Network Liaison for assistance.

What are the four developmental delay visits?

Developmental delay visits are a current limited benefit for some members. In 2016, Prevea360 Health Plan will offer habilitative benefits to some groups upon renewal; these habilitative benefits will replace the four developmental delay visits used in the past. Not all members will have habilitative or developmental delay benefits. Providers should verify members’ eligibility.

If a patient starts physical therapy under the care registration and a month later starts occupational therapy, are these both counted against the eight care registered visits?

If the care registration was completed for physical therapy, but occupational therapy will be used to treat a different body part, it is a separate instance of care and occupational therapy would need a separate (new) prior authorization.
For example, if care registration is completed for physical therapy for body part A, but occupational therapy is later needed for body part B, then the provider would need a new separate authorization for body part B.

Can we publish or send providers a list of diagnosis codes that qualify for the habilitative benefit?

Because a large number of diagnosis codes could be categorized for both habilitative and rehabilitative services, neither Prevea360 Health Plan nor NIA Magellan can provide a definitive list of codes. Providers determine which treatment the diagnosis code qualifies for, as they determine whether the patient requires rehabilitative or habilitative treatment.