CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Outpatient and Office Physical and Occupational Therapy Prior Authorization (OrthoNet) Coverage Criteria

Defines OrthoNet-managed prior authorization requirements and processes for outpatient and office PT/OT services for Anthem Blue Cross and Blue Shield (including Wisconsin) products listed; describes provider workflows and exclusions.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyOutpatient and Office Physical and Occupational Therapy Prior Authorization (OrthoNet) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2015

Next Review DateN/A

Key ActionObtain pre-certification through OrthoNet for all outpatient and office PT/OT services after the initial evaluation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 business daysauth turnaround

48 hourssubmission grace period

844-282-6994OrthoNet phone

844-216-1599OrthoNet fax

97001, 97003evaluation codes exempt

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Coverage and Medical Necessity Criteria

Precertification requirement

Covered when ALL of the following are met

Precertification required: Outpatient and office PT/OT services following the initial evaluation must have pre-certification via OrthoNet.

Initial evaluation (CPT 97001/97003) is excluded from precertification.

General Authorization Criteria

Coverage and authorization rules for initial evaluations and pre-certification

Initial evaluation coverage: Initial PT and OT evaluations do not require pre-certification and may be performed without prior review.

Submit CPT 97001 or 97003 on the claim.

Authorization transmission: OrthoNet transmits a nightly authorization file (Monday–Friday) to Anthem which is loaded into the claims system.

Providers do not need to submit pre-cert number on claim; system aligns claim with authorization.

Secondary payer: Pre-certification is not required when Anthem is the secondary insurer to any commercial insurer or any Medicare product, program or plan.

The following provider types are excluded from OrthoNet pre-certification review: Chiropractors, Acupuncturists, Massage Therapists, Home Health Centers or Agencies, and Skilled Nursing Facility inpatient services. These providers’ services are not evaluated under the outpatient/office PT/OT utilization management program.

The program also excludes services delivered in certain settings. Pre-certification review does not apply to services rendered as part of the emergency room, hospital inpatient, urgent care, observation room, home setting, or skilled nursing facility inpatient care.

Specific product lines are excluded from the program and therefore are not subject to OrthoNet pre-certification. Excluded product types include Group Medicare Advantage, Medicaid, Medicare supplement, Medicare Part D, Anthem National Accounts (ANA), Federal Employee Program (FEP), and BlueCard plans.

When Anthem is the secondary payer, pre-certification is not required. This applies whenever Anthem is secondary to any commercial insurer or any Medicare product, program, or plan; providers should follow the primary payer’s authorization requirements in those situations.

Code Lists and Billing Modifiers

Initial evaluation codes (no pre-certification required)CPTCovered

97001	PHYSICAL THERAPY EVALUATION
97003	OCCUPATIONAL THERAPY EVALUATION

Initial Evaluation CPT CodesCPTCovered

97001	PHYSICAL THERAPY EVALUATION
97003	OCCUPATIONAL THERAPY EVALUATION

Billing ModifiersModifier

GP	Modifier for physical therapy services (CMS/Medicare Advantage requirement)
GO	Modifier for occupational therapy services (CMS/Medicare Advantage requirement)

What Providers Must Do / Authorization Workflow

Prior Authorization

Prior Authorization Required

All outpatient and office physical therapy (PT) and occupational therapy (OT) services after the initial evaluation require utilization management precertification through OrthoNet. OrthoNet will also perform retrospective reviews as applicable per contract. The initial evaluation (CPT 97001 for PT evaluation and 97003 for OT evaluation) does not require pre-certification; submit initial evaluation codes on the claim to ensure proper reimbursement.

Pre-certification required for services scheduled on or after 2015-11-01
Initial evaluation codes 97001 (PT) and 97003 (OT) should be submitted on the claim

Note

How to Request Authorization

Providers may request authorizations by fax, phone, or via the OrthoNet website. OrthoNet transmits authorizations Monday–Friday to Anthem via a nightly file which is loaded into the claims system. When Anthem is secondary to another commercial insurer or any Medicare product, pre-certification is not required.

By fax: OrthoNet Fax Request Form and PT/OT Initial Report Form or Functional Progress Chart (or provider equivalent) to 844-216-1599

Program Background

Anthem implemented a physical and occupational therapy benefit management program effective November 1, 2015. Under this program Anthem contracted with OrthoNet LLC to review outpatient and office therapy requests for medical necessity and to manage prior-authorization workflows for participating products.

Key Definitions

OrthoNet — definition / key-value

Entity nameOrthoNet LLC

RoleExternal musculoskeletal management vendor contracted by Anthem to manage outpatient and office PT/OT benefit program

Services providedApplies evidence‑based practices and works with PT/OT providers to review medical necessity for outpatient and office therapy services

Program scopeManages utilization for outpatient and office PT/OT services in Indiana, Kentucky, Missouri, Ohio, and Wisconsin

LocationWhite Plains, NY

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyOutpatient and Office Physical and Occupational Therapy Prior Authorization (OrthoNet) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2015

Next Review DateN/A

Key ActionObtain pre-certification through OrthoNet for all outpatient and office PT/OT services after the initial evaluation.

SourceLink

On This Page

By phone: OrthoNet call center 844-282-6994 (open 8am–5:30pm all time zones); fax supporting documentation to 844-216-1599

By website: www.orthonet-online.com (New User Account required to submit online)

OrthoNet sends nightly authorization files to Anthem Monday–Friday

Documentation Required

Incomplete Documentation Process

If the OrthoNet Fax Request Form and/or required clinical documentation are missing or incomplete, OrthoNet will contact the provider to request additional information. Providers may supply the OrthoNet forms or their own forms/clinical notes that provide the same information.

Required submission materials: OrthoNet Fax Request Form and PT/OT Initial Report Form or Functional Progress Chart, or provider-equivalent documentation
OrthoNet will call the provider to obtain missing information

Billing Rule

Claim Submission & Modifier Guidance

Providers billing Medicare Advantage must append modifier GP for all physical therapy services and modifier GO for all occupational therapy services. For commercial claims submitted on CMS-1500, GP/GO modifiers are requested though not required. UB-04 claims do not require GP/GO modifiers. An authorization number reflects medical necessity determination only and is not a guarantee of payment; payment depends on provider contract and the member's certificate of coverage.

Medicare Advantage: append modifier GP for PT and GO for OT
Commercial (CMS-1500): GP/GO modifiers requested but not required
UB-04: GP/GO modifiers not required
Authorization is not a payment guarantee; verify contract and member benefits

Denial Risk

Denial Criteria Disclosure

If a pre-certification request is denied, providers may request the specific OrthoNet criteria applied to that denial and OrthoNet will provide it.

Providers can request the exact review criteria used in a denial determination