Physical Medicine Management
Last Updated: Friday, September 20, 2024
- wny
- neny
Effective May 1, 2024, New York providers will be required to request prior authorization for outpatient physical medicine and home health services for members.
The change includes the following outpatient services (see below for more information):
- Physical therapy (PT)*
- Occupational therapy (OT)*
- Home health (HH)**
Outpatient Service(s): Physical Therapy, Occupational Therapy
Applicable Members and Exclusions:
This prior authorization change applies to members in Commercial plans.
*ASO, FEP, and Medicare Advantage are excluded from the prior authorization requirement.
Outpatient Service(s): Home Health
Applicable Members and Exclusions:
This prior authorization change applies to members in Commercial plans and ASO groups.
**Medicare Advantage is excluded from the prior authorization requirement; FEP prior authorization is not required for initial visits, per the plan limit. If a member needs additional visits (beyond the plan limit), then prior authorization is required.
New: Highmark has made the decision not to add chiropractic CPT codes to New York’s prior authorization list.
Resources
We have a number of resources available to assist providers with the change and the electronic authorization process for these outpatient services.
Frequently Asked Questions
- Physical Medicine Management Program Changes
- Skilled Nursing Facility, Inpatient Rehabilitation Facility, Inpatient Hospice & Home Health
Instructional Videos
Click the links below to view the videos which walk you through the authorization process in Availity. If you experience an issue, please refresh your browser. If the issue persists, contact resourcecenter@email.highmark.com.
Prior Authorization
- Submitting a Prior Authorization for Outpatient PT, OT
- Submitting a Prior Authorization for Home Health
- Submitting a Prior Authorization for Inpatient Hospice
- Submitting a Prior Authorization for Inpatient Rehab Facility Services
- Submitting a Prior Authorization for Outpatient Speech Therapy
- Submitting a Prior Authorization for Skilled Nursing Facility
Extension Request
- wpa/ nepa
- cpa/ sepa
- de
- wv
Utilization management (UM) of outpatient physical medicine services — physical therapy, occupational therapy, and manipulation services — is Highmark-managed as of December 4, 2023.
For more information, read the FAQs below.
The preferred — and fastest — method to submit preauthorization requests and receive approvals is the online provider portal.
Reference Materials
Instructional Videos
Click the links below to view the videos. If you experience an issue, please refresh your browser. If the issue persists, contact resourcecenter@email.highmark.com.
Availity
*Scroll to see video disclaimer
Authorization Requirements
For additional information and resources on submitting authorizations, click the link below.
Helion Arc Technology Platform Update – Authorization End Dates
Helion is making a change to how prior authorization end dates are handled in the Helion Arc Technology Platform to better align with the Predictal Auth Automation Hub in Availity. This change will shift the authorization end date from the last day of the calendar year to a fixed 180-day period. This means providers will no longer need to resubmit authorizations on Jan. 1, 2025. During the transition period, Predictal will be the primary source for accurate authorization end dates. Providers are still responsible for verifying benefits before providing care.
NOTE: Notice of Coverage Approvals are not a guarantee of payment.
High Performing Providers
The High Performing Provider (HPP) designation is replacing the former Pathways Program effective January 1, 2025, for providers in all Highmark service areas. It is designed to give Highmark a formal process and framework for identifying and rewarding high-performing providers based on a defined set of metrics, allowing qualifying providers to have greater self-management.
For more information, read our Special Bulletin and FAQs below.
What Is Helion?
Helion is a health care technology and services company that helps payers cultivate high-performing networks while empowering providers to operate at their best — and in doing so, help patients heal better.
To learn more about Helion, click the link below.
*By accessing this video, I understand that I am leaving the Highmark PRC website and will be redirected to an external website operated by a third-party platform provider. Any use of the third-party platform provider’s website and any information you provide will be subject to and governed by the terms of the third party, including those relating to confidentiality, data privacy, and security.
Related Links
For additional information and resources on submitting authorizations:
