Prior Authorization Program for Outpatient Physical Medicine Services
Customize your policy alerts
Sign up for all Ambetter Georgia policy alerts
Know when Ambetter Georgia releases new policies or updates existing guidance.
Monitor payer policy activity
Governs prior authorization requirements and NIA/RadMD workflows for outpatient physical, occupational, and speech therapy services provided to Ambetter from Nebraska Total Care members.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Outpatient Physical Medicine Prior Authorization Criteria
Coverage and prior authorization criteria for Ambetter from Nebraska Total Care members receiving outpatient physical medicine services from participating providers.
Included and excluded settings
- Included settings: Outpatient office, outpatient hospital, and home health (when part of the outpatient program).
- Excluded settings: Hospital emergency department, inpatient, acute rehabilitation hospital inpatient, inpatient and outpatient skilled nursing facilities, and home health services provided in excluded settings — for those settings follow Ambetter from Nebraska Total Care policies.
Evaluation Codes, Visit Counting, and Authorization Validity
| Initial evaluation CPT codes (PT/OT/ST) | Initial evaluation CPT codes are exempt from prior authorization for participating providers. |
| Policy note | Initial Physical, Occupational and Speech Therapy evaluation codes do not require authorization; other billable CPT codes on the same date do require authorization or must be requested within 5 business days to be backdated. |
What Providers Must Do to Obtain Authorization
Prior authorization required for all outpatient PT/OT/ST
Prior authorization is required for all outpatient Physical, Occupational, and Speech Therapy services provided to Ambetter from Nebraska Total Care members by participating providers, effective January 1, 2022. Initial evaluation CPT codes do not require authorization for participating providers, but any other billable CPT codes on the same date of service do require authorization prior to billing.
How to obtain authorization (RadMD preferred; phone & upload/fax guidance)
Submit authorization requests via RadMD (preferred) or by phone at 1-800-424-9232. Clinical records may be uploaded directly in RadMD (preferred) immediately after completing the authorization request, or faxed to 1-800-784-6864 using the NIA fax coversheet; include the RadMD tracking number on the coversheet.
- RadMD (www.RadMD.com) is the preferred submission method.
- Phone: 1-800-424-9232 if RadMD cannot be used.
- Fax clinical records to 1-800-784-6864 using the NIA fax coversheet; ensure the tracking number on the coversheet matches the request.
Backdating allowed — 5 business day request window
If services that require authorization are rendered on the same date as the initial evaluation, providers have up to 5 business days (outpatient and home health) from the initial visit to request approval so the authorization can be backdated to include the evaluation date.
- 5 business days to request approval for outpatient settings.
- 5 business days to request approval for Home Health settings.
Track status and exchange communications via RadMD
Providers can track and view case-specific communications, confirm uploaded clinical information, and upload additional documents via RadMD using 'View Request Status' or 'Track an Authorization' (a tracking number or authorization number is required). Communications are defaulted to paperless email linking to RadMD where PHI may be viewed after login.
- Use 'View Request Status' on RadMD to check authorization status and view received uploads.
- 'Track an Authorization' or 'Search by Tracking Number' allows users who did not submit the original request to view status and upload clinical info (tracking number required).
- Notifications are sent by email to the person who submitted the request with a link to RadMD; no PHI is contained in the email.
Peer-to-peer and reconsideration available; 5-business-day reconsideration window
Peer-to-peer telephone consultations are available at any point during the prior authorization process and are also available during reconsideration; if a denial is issued, reconsideration must be initiated within 5 business days of the denial (and before a formal appeal).
- To initiate peer-to-peer, providers may call 1-800-424-9232.
- Reconsideration is initiated by uploading additional clinical information via RadMD or fax using the case-specific coversheet within 5 business days of denial.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.