System Update for Section 68, Occupational Therapy Services and Section 85, Physical Therapy Services: Evaluation Services Claims will now Process with No Prior Authorization (PA), CR 40732

March 25, 2014

The system has been updated to process evaluation services without a PA approval. You may now submit claims for evaluation service codes 97001, 97002, 97003, 97004.

On March 5, 2014, we sent the listserv message below:

Attention Section 68, Occupational Therapy Services and Section 85, Physical Therapy Services: No Prior Authorization (PA) Required for Evaluation Service Codes 97001, 97002, 97003, 97004, CR 40732

Effective January 1, 2014, Section 68, Occupational Therapy Services and Section 85, Physical Therapy Services no longer require PA for the following procedure codes for evaluation service:

  • PT- 97001 and 97002

  • OT- 97003 and 97004

In order to streamline the PA process for these therapy services, the process has been revised from the one that was originally communicated with the adopted final rules for January 1, 1204 and the listserv notice published on January 16, 2014.

We are currently reconfiguring the system to process these evaluation services without a PA approval. Please hold your claims until further notice. We will notify you when the system has been updated.

You can conduct the evaluation visit and then submit a PA request for the medically necessary therapy treatment services. Please include the evaluation report, the requested treatment services, and requested number of visits as part of your PA request. If your organization has already submitted PA requests for evaluation services, you may proceed to provide those evaluation services at this time. A PA approval is not required for the evaluation visit. A PA approval is required for the medically necessary treatment services.

Note:

  • Members under the age of 21 years are exempt from PA for all PT & OT services.

  • All hospital inpatient OT & PT services are exempt from PA for all ages.

If you have any questions, please contact your Provider Relations Specialist