CurrentFidelis CarePolicy N/A

Physical, Occupational, and Speech Therapy (PT/OT/ST) Coverage Criteria

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Removes prior service limits and covers medically necessary PT, OT, and ST visits ordered by a physician or other licensed professional for Fidelis Care members effective January 1, 2021.

Policy Summary

PayerFidelis Care

PolicyPhysical, Occupational, and Speech Therapy coverage criteria

Policy CodePolicy N/A

Change TypeService limits removedcoverage criteria added

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionObtain a physician or other licensed professional order to document medical necessity for PT, OT, and ST visits.

SourceLink

POLICY UPDATE CHANGES

Fidelis Care will remove service limits on physical therapy (PT), occupational therapy (OT), and speech therapy (ST).

Medically necessary PT, OT, and ST visits ordered by a doctor or other licensed professional will be covered.

removedPT/OT/ST visit caps

2021-01-01policy start date

Coverage Criteria for PT, OT, and ST

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CurrentFidelis CarePolicy N/A

Physical, Occupational, and Speech Therapy (PT/OT/ST) Coverage Criteria

Customize your policy alerts

Sign up for all Fidelis Care policy alerts

Know when Fidelis Care releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Removes prior service limits and covers medically necessary PT, OT, and ST visits ordered by a physician or other licensed professional for Fidelis Care members effective January 1, 2021.

Policy Summary

PayerFidelis Care

PolicyPhysical, Occupational, and Speech Therapy coverage criteria

Policy CodePolicy N/A

Change TypeService limits removedcoverage criteria added

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionObtain a physician or other licensed professional order to document medical necessity for PT, OT, and ST visits.

SourceLink

POLICY UPDATE CHANGES

Fidelis Care will remove service limits on physical therapy (PT), occupational therapy (OT), and speech therapy (ST).

Medically necessary PT, OT, and ST visits ordered by a doctor or other licensed professional will be covered.

removedPT/OT/ST visit caps

2021-01-01policy start date

Coverage Criteria for PT, OT, and ST

Medically Necessary PT/OT/ST

Covered when ALL of the following are met

Coverage conditions: 1) The service is physical therapy (PT), occupational therapy (OT), or speech therapy (ST); 2) The visit is medically necessary; 3) The visit is ordered by a doctor or other licensed professional.

Service limits have been removed; frequency and quantity are determined by medical necessity.

Any services that do not meet medical necessity criteria or that lack an order from a doctor or other licensed professional are not covered under this policy. Fidelis Care removed prior numeric service limits effective January 1, 2021; coverage instead depends on the service meeting medical necessity and having an appropriate provider order.

Visits that are not medically necessary are not covered.

What Providers Must Do

Note

Medically Necessary and Ordered

Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) must be medically necessary and ordered by a physician or other licensed healthcare professional to be covered. There are no routine service limits; coverage is based on medical necessity and provider order.

Orders must be from a physician or other licensed professional.
No visit limits — services covered when medically necessary.

Documentation Required

Actionable Provider Highlight

Providers: ensure an order is on file and that documentation supports the medical necessity of each PT/OT/ST visit. Include treatment goals, progress notes, and frequency/duration rationale in the medical record.

Prior Authorization

Order Required

A physician or other licensed professional order is required for coverage of PT, OT, and ST services. Submit the order and any supporting documentation with claims as required by Fidelis Care.

Order must be present before or at time of service.
Include order reference on claim submissions when applicable.

Denial Risk

Denial Risk for Unordered or Non‑Medically Necessary Care

Services that are not medically necessary or that are not ordered by a physician or other licensed professional may be denied. Claims lacking supporting documentation of medical necessity or a valid order are at risk for denial.

Denial risk for services without medical necessity documentation.
Denial risk for services without a physician or licensed professional order.

Background

Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) are rehabilitative services that generally require clinician assessment and a provider order. Effective January 1, 2021, Fidelis Care removed service quantity limits for PT, OT, and ST and will cover visits when they are medically necessary and ordered by a doctor or other licensed professional.

Key Definitions

Medically necessary visits — definition

DefinitionVisits for physical therapy (PT), occupational therapy (OT), or speech therapy (ST) that are ordered by a doctor or other licensed professional and are appropriate for the member's condition.

Order requirementA physician or other licensed professional must order the visit for it to be covered.

Coverage basisCoverage is determined by medical necessity rather than by pre-set visit limits (service limits removed effective Jan 1, 2021).

Denial riskServices that are not medically necessary or that lack a proper order may be denied.

ScopeApplies to PT, OT, and ST visits provided to Fidelis Care members.

Policy Summary

PayerFidelis Care

PolicyPhysical, Occupational, and Speech Therapy coverage criteria

Policy CodePolicy N/A

Change TypeService limits removedcoverage criteria added

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionObtain a physician or other licensed professional order to document medical necessity for PT, OT, and ST visits.

SourceLink

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