CurrentHealthfirstPolicy PO-RE-128v2

Part B Custodial Services-Skilled Therapy and Vaccine Services

Defines reimbursement and billing guidelines for Medicare Part B skilled therapy (PT/OT/ST) and vaccine administration services when billed by nursing facilities for custodial Healthfirst members, affecting Medicaid Advantage Plus/MAP (CompleteCare) and Medicare PPO lines of business.

Policy Summary

PayerHealthfirst

PolicyPart B Custodial Services-Skilled Therapy and Vaccine Services

Policy CodePolicy PO-RE-128v2

Change TypeNo material change

Effective DateNov 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization for PT, ST, and OT visits and submit correct CPT/HCPCS, diagnosis codes and modifiers when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PT/OT/ST/VaxServices identified as billable under Part B

Prior authTherapy visits requiring prior auth

CMS-1450Required claim form

211-228Accepted bill types

MA+/PPOApplies to

Policy Summary

PayerHealthfirst

PolicyPart B Custodial Services-Skilled Therapy and Vaccine Services

Policy CodePolicy PO-RE-128v2

Change TypeNo material change

Effective DateNov 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization for PT, ST, and OT visits and submit correct CPT/HCPCS, diagnosis codes and modifiers when applicable.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Part B Custodial Services

Services may be reimbursed separately from the facility per diem when billed by the nursing facility and when ALL of the following are met:

ALL of the following

Services eligible include PT, OT, ST, and vaccine administration for custodial residents and residents who have exhausted inpatient skilled services.
A comprehensive written treatment plan must be documented and may be periodically reviewed to justify continued Part B custodial services.
Services must be ordered and directed by a licensed treating practitioner (MD, DO, PA, NP).
Care must be delivered or supervised by a licensed healthcare professional.
Prior authorization is required for PT, OT, and ST visits.
ALL of the following
- Providers must submit the correct and current CPT/HCPCS procedure codes and diagnosis codes; include applicable modifiers when required.
- Facility billing must use CMS-1450 (UB04) with bill types 211-228 and the appropriate custodial revenue codes (e.g., 0420, 0424, 0430, 0434, 0440, 0444, 0634, 0771).
Reimbursement is determined by the providerâs contract rates; claims not adhering to this policy will be denied or rejected and are subject to timely filing and appeals per the provider contract and Healthfirst Provider Manual.
This policy applies only to the specified lines of business identified in the policy.

ONE OF

Physical Therapy (PT) - non-surgical treatment for identification, restoration, and improvement of impaired function.
Occupational Therapy (OT) - treatment to identify and alleviate limitations in activities of daily living and support independence.
Speech Therapy (ST) - treatment to improve speech, language, memory, and problem-solving skills.
Vaccine Administration - proper handling, preparation, and delivery of vaccines; billed using custodial vaccine revenue code (0771).

Billing Forms, Codes, and Prior Auth Thresholds

inv-03: Prior Authorization Threshold — highlight that PT, ST, and OT visits require prior authorization and any threshold details.

Claim form and bill typesClaim Form: CMS-1450 (UB-04); Bill Types: 211-228

Prior Authorization RequirementPrior authorization is required for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) visits.

Provider responsibilitiesSubmit correct and current CPT/HCPCS and diagnosis codes; include applicable modifiers. Services may be billed by the facility on a separate claim.

Provider Responsibilities for Authorization and Claims Submission

Prior Authorization

Prior authorization plus correct claim codes and form required

Prior authorization is required for Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) visits. When submitting claims, providers must submit the correct and most up-to-date CPT/HCPCS procedure and diagnosis codes and include applicable modifiers. Use CMS-1450 (UB04) with bill types 211–228 and the appropriate custodial revenue codes (e.g., 0420/0424/0430/0434/0440/0444/0634/0771) when billing these services separately from the facility per diem.

Obtain prior authorization for all PT, OT and ST visits before services are rendered.
Submit correct CPT/HCPCS procedure codes and diagnosis codes, using the most current industry-standard codes.
Include a modifier when applicable with the corresponding CPT/HCPCS code.
File claims on CMS-1450 (UB04) using bill types 211–228 and the specified custodial revenue codes (0420, 0424, 0430, 0434, 0440, 0444, 0634, 0771).

Definitions

Physical Therapy (PT)

DefinitionPhysical Therapy (PT): Non-surgical treatment necessary for identification, restoration, and improvement of functions impaired by illness, disease, surgery, trauma or injury; includes therapeutic exercise, physical activity, and training in activities of daily living.

PurposeRestores function and improves mobility to support activities of daily living.

Delivery RequirementsCare must be delivered or supervised by a licensed healthcare professional and ordered by a qualified practitioner.

Occupational Therapy (OT)

DefinitionOccupational Therapy (OT): Non-surgical treatment to identify and alleviate mental and/or physical conditions that limit an individual’s ability to perform activities of daily living; focuses on increasing independence and minimizing recurrence through education, therapeutic exercise, and activity at home or at work.

FocusEmphasis on independence in ADLs and prevention of recurrent injury or functional decline.

Order and SupervisionServices must be ordered by a licensed treating practitioner and delivered or supervised by a licensed healthcare professional.

Speech Therapy (ST)

DefinitionSpeech Therapy (ST): Treatment to improve speech and language skills, enhance expression and comprehension, and address related cognitive skills such as memory and problem-solving.

GoalsImprove communication, language comprehension, memory, and problem-solving to support daily functioning.

AuthorizationSpeech therapy visits require prior authorization when billed under Part B for nursing facility custodial residents.

Vaccine Administration

DefinitionVaccine Administration: The act of giving vaccines to individuals, including proper handling, storage, preparation, and delivery to ensure efficacy and safety.

ScopeIncludes all steps necessary to administer vaccines safely when billed as Part B ancillary services by the nursing facility.

Billing ContextVaccine administration is an eligible Part B service for custodial residents when criteria and documentation requirements are met.