Dear Provider,
As you know, effective 11/1/2024, BCBSNC will require that all providers obtain prior authorization (PA) for physical therapy (PT) codes billed to fully insured plans.
HNS strongly disagrees with this policy, and like you, we are extremely frustrated and concerned about its impact. We continue to work with BCBSNC to obtain clarification regarding specifics surrounding how this policy will work for HNS providers and will provide you with updated information as we have it.
In the meantime, we are outlining some important action steps you should take.
ACTION STEP #1: Carefully Review the Following Information with All Pertinent Staff Members.
-The Policy: Effective 11/1/2024, 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 prior authorization (PA) in order to be reimbursed.
Utilizing the clinical guidelines linked below, the program will consider individual clinical details, and services to be rendered, to determine the number of visits (where PT services are to be performed) to authorize.
-Impacted Plans: This new PA requirement only applies to Fully Insured Commercial BCBSNC Plans. At this time, it will not apply to FEP, SHP, out-of-state plans, or self-funded employer plans.
-Impacted Services: The PT services triggering the PA requirement, include, but are not limited to services represented by the following codes:
97010, 97012, 97014, 97016, 97024, 97026, 97032, 97034, 97035,
97110, 97112, 97124, 97140, 97530, 97750, 97760, 97763
Importantly, under this new policy, you will not be required to obtain PA for any service that is not a PT service (e.g. E/M, x-ray, and CMT services will not require PA.)
-Important Note – 97012 & 97014: Unfortunately, the Clinical Guidelines governing this PA program, which are linked below, seem to indicate that PA will never be granted for Traction (97012) and Unattended Electrical Stim (97014) because the Guidelines state these services are never considered medically necessary. As this is a substantial change to BCBSNC policy, we have asked that they clarify whether we have interpreted this correctly and will report back to the network once we know more.
-Therapy Modifier: To process claims correctly, Modifier GP will be required on all E/M and treatment code lines. (Note: HNS is seeking additional clarification on this requirement as it relates to CMT codes billed on the same DOS as any PT service.)
-How to submit a PA request: Beginning on 10/21/2024, you will be able to submit PA requests for DOS on/after 11/1/2024 as follows:
Online: Through the Carelon provider portal, which is available 24/7 and processes requests in real-time based on the Clinical Guidelines linked below. (You will need to register for this portal when first attempting to use it and may find details about registering in the FAQs linked below.)
By phone: Providers may also call Carelon, M-F (8am-5pm ET) at 1-866-455-8414.
Importantly, on 10/21/2024, you should begin entering and seeking PA for patients on established treatment plans which include PT services that will be rendered on and after 11/1/2024 to ensure you have ample time to obtain the required PA for those patients.
-Identifier to Use When Requesting PA: When seeking to obtain PA for PT services, you will use HNS’ NPI (1093773392) for all authorization requests.
-Billing of PT Services as Non-Covered: If the PA program ultimately determines that a PT service or a visit with PT services is medically unnecessary and no further PA will be authorized, those impacted services would be considered non-covered and could be billed to the patient under the right circumstances. Because there will be several requirements associated with this, HNS will be emailing you separately regarding this topic.
Action Step #2: Carefully Review the PA Program’s Applicable Guidelines, FAQs, and Checklist.
-Carelon Medical Benefits Management (Carelon) will manage the PA process on behalf of BCBSNC, and BCBSNC will utilize Carelon’s clinical guidelines to determine when and how to grant PA.
-For your review and reference, we have embedded those guidelines, along with related FAQs and an informative checklist about the program here: BCBSNC-Carelon PA for PT Guidelines, FAQs, and Checklist. Please click this link and review these documents yourself. Then review them with pertinent members of your team.
Action Step #3: You and Pertinent Staff Should Attend One of the PA Program’s Training Webinars.
-In addition to carefully reviewing the information above with your staff, we strongly recommend that you and your staff attend one of Carelon’s upcoming online training sessions to learn more about the PA process. HNS will be attending these sessions as well so that we may better help you understand this program.
-The webinars are currently scheduled for 12:00pm on October 2nd, 16th, 30th, and November 6th. You may visit the following link (and scroll to the bottom of the page) to register for one of the sessions: Changes in prior authorization for Blue Cross NC outpatient therapy requests effective November 1.
In closing, we want to again reiterate, that like you, we believe this PA requirement is unnecessary and should not apply to HNS providers. However, BCBSNC has decided to leave it in place, and as such, over the coming weeks, HNS will continue to provide you with helpful information and materials to help make sure you all are well equipped to navigate the process.
Sincerely,
HNS