CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Therapy Services

Rules for notification and prior authorization of outpatient physical and occupational therapy services for Blue Cross & Blue Shield of Rhode Island Medicare Advantage members; applies to providers ordering or delivering therapy services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTherapy Services

Policy CodePolicy N/A

Change TypeAdded prior authorization requirement

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionOrdering therapist must notify the BCBSRI Physical and Occupational Services vendor to administratively authorize up to 14 visits and obtain prior authorization for visits beyond 14.

SourceLink

POLICY UPDATE CHANGES

Medicare Advantage Plans require notification for up to 14 visits per episode of care and prior authorization for visits beyond the 14th effective 1/1/2026.

14visits administratively authorized per episode without prior authorization

Medicare Advantageplans this policy applies to

01/01/2026policy effective date

09/17/2025last review date

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Coverage and Applicability

Initial and Continued Therapy Authorization

Covered when the following administrative and documentation steps are completed.

Episode authorization and documentation: 1) Notification to the BCBSRI Physical and Occupational Services vendor is completed by the ordering therapist to administratively authorize up to 14 visits per episode (visits 1–14, including the initial assessment/evaluation); 2) The ordering physical or occupational therapist must initiate and complete the notification/authorization with the BCBSRI Physical and Occupational Services vendor and the ordering physician must maintain documentation supporting the clinical appropriateness of the services; 3) Any physical or occupational therapy beyond 14 visits per episode must receive prior authorization from the BCBSRI Physical and Occupational Services vendor for continued medical necessity.14 visits

Applies to Medicare Advantage plans only

This policy applies to Medicare Advantage plans only. Rules for notification and prior authorization described here are specific to BCBSRI Medicare Advantage products and may not apply to commercial, Medicaid, or other lines of business; providers should consult the appropriate plan documents for non‑Medicare Advantage members.

This medical policy is provided for informational purposes only and is not a guarantee of payment. Coverage, benefits, and member eligibility are determined by the member's subscriber agreement, member certificate, and/or employer agreement, which take precedence over this policy. BCBSRI may review and revise this policy at any time.

Coding and Visit Thresholds

Covered codes if approved by vendormixedCovered

No codes listed

Visit authorization threshold

Authorization thresholdUp to 14 visits per episode of care are administratively authorized via notification to the BCBSRI Physical and Occupational Services vendor; visits beyond 14 require prior authorization from that vendor.

ScopeApplies to physical services and occupational services per episode of care (includes initial assessment/evaluation).

Effective actionProvider must notify the BCBSRI Physical and Occupational Services vendor to obtain administrative authorization for visits 1–14; submit prior authorization request for any visit >14.

What Providers Must Do

Prior Authorization

Notification for first 14 visits

Notification to the BCBSRI Physical and Occupational Services vendor is required to administratively authorize up to 14 visits per episode of care. For visits 1-14 (including the initial assessment/evaluation), the provider must notify the vendor to secure this administrative authorization.

Notification covers visits 1-14 per episode of care (includes initial assessment/evaluation).
The vendor will administratively authorize payment for up to 14 visits after notification.

Documentation Required

Provider documentation and initiation

The ordering Physical or Occupational Therapist must initiate and complete the notification and any required authorization with the BCBSRI Physical and Occupational Services vendor. The ordering clinician (and ordering physician where applicable) must retain documentation supporting the clinical appropriateness of the services and ensure the authorization is completed accurately.

Background

This policy describes the administrative authorization and medical necessity review processes for outpatient physical and occupational therapy for BCBSRI Medicare Advantage members. Providers must notify the BCBSRI Physical and Occupational Services vendor to administratively authorize up to 14 visits per episode; the ordering Physical or Occupational Therapist is responsible for initiating and completing that notification/authorization and the ordering physician must maintain documentation supporting clinical appropriateness. Visits beyond the 14th require prior authorization from the vendor and services provided beyond 14 visits without that prior authorization risk denial of payment.

Definitions

Visit

DefinitionA visit is defined as the date of service on which the physical therapy or occupational therapy treatment is rendered.

Applies toPhysical and occupational therapy services covered under this policy for Medicare Advantage plans.

Use in authorizationVisit counting for the 14-visit administrative authorization and any required prior authorization is based on the date-of-service on which treatment is provided.