CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prior Authorization of Physical and Occupational Therapy Services

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Defines prior authorization/notification requirements for physical and occupational therapy services for Blue Cross & Blue Shield of Rhode Island Medicare Advantage members and the vendor processes to obtain authorization. Applies to Medicare Advantage Plans only.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrior Authorization of Physical and Occupational Therapy Services

Policy CodePolicy N/A

Change TypeAdded notification stepadded prior authorization after 14 visitsclarified exclusions

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionThe ordering physical or occupational therapist must initiate and complete notification/authorization with the BCBSRI Physical and Occupational Services vendor.

SourceLink

POLICY UPDATE CHANGES

Notification is required for visits 1-14 per episode of care and will administratively authorize up to 14 visits.

Prior authorization is required for therapy services after the 14th visit per episode of care.

Telehealth, Home Health, and Inpatient physical and occupational therapy services do not require prior authorization or notification.

14visits administratively authorized

01/01/2026policy effective

MA onlyapplicability

Evicorevendor

Outpatient Therapy Coverage & Authorization

Outpatient therapy authorization criteria

Coverage and authorization workflow for outpatient physical and occupational therapy services for Medicare Advantage plans:

Visits 1-14 per episode: notification to the BCBSRI Physical and Occupational Services vendor is required; notification administratively authorizes up to 14 visits per episode of care.

After visit 14: prior authorization is required for additional physical or occupational therapy services; requests beyond 14 visits are subject to a prior authorization review for medical necessity by the BCBSRI Physical and Occupational Services vendor.

Exclusions: Telehealth, Home Health, and Inpatient physical and occupational therapy services are excluded from the notification and prior authorization requirements.

Provider responsibilities: The ordering physical or occupational therapist must initiate and complete the notification/authorization with the BCBSRI Physical and Occupational Services vendor. The ordering physician must maintain documentation supporting the clinical appropriateness of the ordered services.

Benefit variance note: Benefits may vary by contract; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for specific outpatient rehabilitation benefits.

Codes and Visit Limits

Therapy service codesmixedCovered

See linked master code list

2026 codes for physical and occupational therapy services; coverage contingent on approval by the BCBSRI Physical and Occupational Services vendor.

inv-03: Visits administratively authorized — 14 per episode of care.

Visits administratively authorizedNotification administratively authorizes up to 14 visits of physical or occupational therapy per episode of care.

ScopeApplies to visits 1–14 per episode, including the initial assessment/evaluation.

Action requiredOrdering therapist must notify the BCBSRI Physical and Occupational Services vendor to obtain the administrative authorization.

Provider Notification and Authorization Requirements

Prior Authorization

Initiate notification/authorization with BCBSRI vendor

The ordering physical or occupational therapist must initiate and complete the notification/authorization with the BCBSRI Physical and Occupational Services vendor; the ordering physician must maintain documentation supporting the clinical appropriateness of the ordered services.

Documentation Required

Notify for visits 1–14 to obtain administrative authorization

Notification to the BCBSRI Physical and Occupational Services vendor is required for visits 1–14 per episode of care and will administratively authorize up to 14 visits (including the initial assessment/evaluation).

Prior Authorization

Obtain prior authorization for visits beyond 14

Any therapy visits occurring after the 14th visit per episode of care require prior authorization; requests beyond 14 visits are subject to a prior authorization review for medical necessity by the BCBSRI Physical and Occupational Services vendor.

Denial Risk

Exempt settings: Telehealth, Home Health, Inpatient

Prior Authorization and Notification are not required for Telehealth, Home Health, or Inpatient physical and occupational therapy services.

Definitions and Vendor Resources

inv-08: Visit — A visit is defined as the date of service the treatment (Physical Therapy or Occupational Therapy) is rendered.

DefinitionA visit is defined as the date of service the treatment (Physical Therapy or Occupational Therapy) is rendered.

IncludesInitial assessment/evaluation is counted within the visit total for the episode of care.

UseVisit counts are used to determine when prior authorization is required (after 14 visits).

inv-09: Physical and Occupational Services vendor / Evicore — Clinical guidelines and authorization processes are maintained on the vendor website.

Vendor for clinical guidelinesClinical guidelines and authorization processes are available on the Physical and Occupational Services vendor website (evicore.com) and via vendor contact numbers.

Vendor contactsEvicore: website evicore.com; phone 888-233-8158; fax 888-540-2406.

Authorization processingNotification and prior authorization requests are submitted through the BCBSRI Physical and Occupational Services vendor per policy requirements.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrior Authorization of Physical and Occupational Therapy Services

Policy CodePolicy N/A

Change TypeAdded notification stepadded prior authorization after 14 visitsclarified exclusions

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionThe ordering physical or occupational therapist must initiate and complete notification/authorization with the BCBSRI Physical and Occupational Services vendor.

SourceLink

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