Physical Medicine Management
Last Updated: Monday, December 16, 2024
Helion Arc Technology Platform Update – Authorization End DatesA change has been made 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. |
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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.
The preferred — and fastest — method to submit preauthorization requests and receive approvals is the online provider portal.
Resources
We have a number of resources available to assist providers with the change and the electronic authorization process for these outpatient services.
AUTHORIZATION TRAINING & RESOURCES
Frequently Asked Questions
- Physical Medicine Management Program Changes
- Skilled Nursing Facility, Inpatient Rehabilitation Facility, Inpatient Hospice & Home Health
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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.
Resources
We have a number of resources available to assist providers with the change and the electronic authorization process for these outpatient services.
AUTHORIZATION TRAINING & RESOURCES
Reference Materials
Authorization Requirements
For additional information and resources on submitting authorizations, click the link below.
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.
Related Links
For additional information and resources on submitting authorizations:
