CurrentFidelis CarePolicy N/A

Physical Medicine Prior Authorization Program

Governs prior authorization requirements and processes for outpatient physical, occupational, and speech therapy services for Fidelis Care members across specified product lines and provider networks.

Policy Summary

PayerFidelis Care

PolicyPhysical Medicine Prior Authorization Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2021

Next Review DateN/A

Key ActionProviders must request authorizations via RadMD (preferred) or by phone and submit same-day initial-evaluation authorizations within 1 business day (outpatient) or 2 business days (home health) to allow backdating.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial evals exemptInitial evals exempt

Oct 1, 2021Program expansion date

2-3 daysTypical turnaround

Outpatient & homeSettings included

Inpatient/ER/SNFSettings excluded

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Authorization and Coverage Criteria

Authorization and coverage criteria

Covered when the following authorization and coverage requirements are met:

Prior authorization is required for all outpatient Physical, Occupational, and Speech Therapy services provided to Fidelis Care members in scope (Medicare, Medicaid, Dual Advantage, Essential, CHP, and Qualified Health plans).

Managed by NIA for Fidelis-contracted providers; out-of-network providers follow Fidelis Care out-of-network rules.

Initial evaluation CPT codes for Physical, Occupational, and Speech Therapy do not require prior authorization for participating providers; however, any other billed CPT codes performed on the same date as the initial evaluation do require authorization.

Covered service settings (program applies only in these settings): Outpatient office, outpatient hospital, and home health.

Excluded settings (do not require/are not managed under this program): Hospital ER, inpatient/observation status, acute rehab hospital inpatient, and skilled nursing facility inpatient (place of service 31 or 32).

ALL of the following

For outpatient settings: if services requiring authorization are rendered on the same date as the initial evaluation, the provider must submit the authorization request within 1 business day to allow NIA to backdate the authorization to the evaluation date of service.
For home health settings: providers must submit the authorization request within 2 business days to allow backdating to the evaluation date of service.

ALL of the following

Additional visits should be requested as an addendum to an existing authorization when appropriate.
A new authorization is required for a new condition or when there has been a lapse in care greater than 30 days for a condition with an expired authorization (submit a new initial request).
A 30-day validity date extension may be requested via the RadMD option when applicable.

ALL of the following

NIA may provide real-time decisions using a clinical algorithm at the time of request based on the requester’s answers to clinical questions.
If not approved immediately, typical turnaround for completion is within 2–3 business days after sufficient documentation is received; some cases may take longer.

ALL of the following

Re-review (with new clinical information) may be initiated within specified timeframes: 60 days for Medicaid; 1 year for Medicare/Dual Advantage; 180 days for Essential/CHP/Qualified Health plans.
Peer-to-peer review and formal appeals via Fidelis Care are available as part of the re-review/appeals process.

Evaluation Codes, Validity, and Lapse Rules

Evaluation codes exemptionCPTCovered

Initial evaluation CPT codes (Physical/Occupational/Speech)

Do not require prior authorization for participating providers; other billed CPT codes, even if performed on the same date as the initial evaluation, require authorization. Providers must request authorization for non‑evaluation codes within 1 business day (outpatient) or 2 business days (home health) to allow backdating.

Lapse in care — new initial request after >30 days

Policy requirementIf there has been a lapse in care greater than 30 days and care is to be resumed for a condition with an expired authorization, providers must submit a new initial authorization request.

When to submitSubmit a new initial request through RadMD when treating a new condition or resuming care after a >30-day lapse for a previously authorized condition.

DocumentationClinical records are required when requesting additional services or a new authorization following a lapse; providers may upload records via RadMD.

Validity date extension — 30-day RadMD option

Allowed extensionA 30-day date extension on the validity period of an authorization is permitted.

How to requestRequest the 30-day validity date extension using the 'Request Physical Validity Date Extension' option in RadMD.

LimitationsDate extensions remain subject to any benefit limits that may restrict the length of time for a given condition or episode of care.

Prior Authorization Process and Provider Responsibilities

Documentation Required

Documentation submission

Documentation required for prior authorization reviews should be submitted promptly and in the correct format to avoid delays. The preferred method is to upload clinical records and supporting documentation directly into RadMD immediately after completing an authorization request; uploads are automatically attached to the case and routed to NIA clinicians for review. If your practice cannot use RadMD, you may fax clinical documentation using the NIA case-specific fax coversheet to 1-800-784-6864. Do not use your own fax coversheet — it will not contain the case-specific tracking information needed. Ensure the tracking number on the fax coversheet matches the tracking number for your request, and submit each case on a separate fax with its own coversheet. Physical medicine practitioners can print the fax coversheet from WWW.RadMD.com or request one from NIA by calling 1-800-424-4952 (Medicaid, Essential, CHP, Qualified Health plans) or 1-800-424-5390 (Medicare and Dual Advantage plans). If additional clinical information is needed during review, NIA may request documents; use the same upload or fax process to respond. When submitting documentation for a denial re-review, follow the same channels (RadMD upload preferred or fax with the case-specific coversheet).

Preferred upload: RadMD (WWW.RadMD.com) — upload directly after completing the authorization request so documentation is auto-attached to the case.
Alternate fax: 1-800-784-6864 using the NIA case-specific fax coversheet (do not use practice coversheets).
Make sure the fax coversheet tracking number matches your request; send each case on its own fax and coversheet.
Need a coversheet? Print from WWW.RadMD.com or call NIA at 1-800-424-4952 (Medicaid/Essential/CHP/Qualified) or 1-800-424-5390 (Medicare/Dual Advantage).

Prior Authorization

Authorization tracking and status

Authorization numbers and tracking numbers allow providers to monitor requests and access case-specific communications. An authorization number will contain at least 12 alphanumeric characters (for example, 12345CNY1234). In some situations where an immediate approval is not issued, the provider will instead receive a numeric tracking number (for example, 123456789). Either the authorization number or tracking number may be used to check case status online or via the IVR telephone system. RadMD’s "View Request Status" and "Request Verification Detail" pages let submitters and other authorized users view status, uploaded/faxed clinical documentation, and case-specific communications (including requests for additional information and determination letters). If you did not submit the original request, use the "Track an Authorization" or "Search by Tracking Number" features in RadMD to view status or upload additional documentation — a tracking number is required.

Authorization number format: at least 12 alpha-numeric characters (e.g., 12345CNY1234).
Tracking number: numeric tracking numbers may be issued when requests are not approved immediately (e.g., 123456789).
Check status: RadMD — use "View Request Status" or "Track an Authorization" / "Search by Tracking Number".
Phone/IVR options: use the Interactive Voice Response system or the NIA call center if needed.

Therapy Definitions

Rehabilitative Therapy — definition

DefinitionRehabilitative Therapy: treatment that seeks to help a member regain a skill or function that was lost due to illness, injury, or disability.

Typical goalsRestore previously held abilities and improve functional independence following disease or injury.

Common settingsCovered in outpatient office, outpatient hospital, and home health settings under the program (excludes inpatient/ER/SNF/acute rehab).

Habilitative Therapy — definition

DefinitionHabilitative Therapy: treatment that seeks to help members develop skills or functions they never had and were incapable of developing on their own (commonly pediatric).

Typical goalsEnable development of age-appropriate skills or functions that were not previously acquired.

Common populationOften provided to pediatric members who have not developed certain skills at an age-appropriate level.

Neurological Rehabilitative Therapy — definition

DefinitionNeurological Rehabilitative Therapy: a supervised program of formal training to restore function for members with neurodegenerative diseases, spinal cord injury, stroke, or traumatic brain injury.

PurposeFocused on restoring neurological function and maximizing recovery following neurologic injury or disease.

Program natureDelivered as a supervised, formal training program tailored to neuro-recovery goals.