BCBS/Carelon Prior Authorization for Physical Therapy Services Program

Effective December 1, 2024, for all BCBSNC fully insured plans, all PT services, following those performed on the patient's initial visit (i.e., all DOS following the visit where the new patient E/M code is billed) will require PA in order to be reimbursed.

Carelon Medical Benefits Management (Carelon) will manage the PA process on behalf of BCBSNC utilizing Carelon's Clinical Guidelines for PT. Under these guidelines, the program will consider individual clinical details, and services to be rendered, to determine the number of visits to authorize (where PT services are to be performed).

For more information about this program, please first click the following link and review the HNS:

BCBSNC Physical Therapy
Prior Authorization Summary

For more detailed information from Carelon about this new program, you may review any of the following resources by clicking on the links below: 

• Carelon Program FAQs
• Carelon PA Program Checklist for PT
• Carelon PA for PT Clinical Guidelines
• Carelon PT Code List (Primary and Adjunct PT Codes)
• Carelon Training Slide Deck