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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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BCBS North Carolina Therapy Updates

  • BCBS North Carolina - Prior Authorization For Blue Cross NC Outpatient Therapy Requests Effective November 1

    1 Oct 2024 3:51 PM | Zachary Edgar (Administrator)

    Effective November 1, 2024, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will transition medical necessity review of outpatient therapy services for Commercial Fully Insured members (including professional and home) to Carelon Medical Benefits Management (Carelon).

    The Carelon Rehabilitation Program reviews treatment plans against clinical appropriateness criteria to help ensure that care aligns with established, evidence-based medicine and service codes that do not warrant skilled care are not approved within the episode of care.

    Program details

    The Carelon Rehabilitation Program reviews treatment plans against clinical appropriateness criteria to help ensure that care aligns with established, evidence-based medicine and service codes that do not warrant skilled care are not approved within the episode of care.

    Blue Cross NC will utilize Carelon’s Outpatient Rehabilitation and Habilitative Services Clinical Guidelines⁠.

    The Rehabilitation Program considers individual clinical details to evaluate the number of authorized visits on a request. Carelon measures progress based on condition management and patient outcomes with additional visits approved as clinically appropriate.

    For outpatient therapy services (including professional and home) that are scheduled to begin on or after November 1, 2024, prior authorization will be required for Blue Cross NC Commercial Fully Insured members beginning with the first treatment visit following the initial evaluation date of service. This program applies to the following outpatient therapies (including professional and home).

    • Physical therapy
    • Occupational therapy
    • Speech therapy

    Initial evaluation date of service

    The initial evaluation CPT® service codes do not require prior authorization. If treatment CPT® service codes are rendered at the initial evaluation date of service, the initial evaluation visit will not require prior authorization. Prior authorization is required for subsequent treatment visits.

    Transition of outpatient therapy care

    Beginning October 21, 2024, the Carelon provider portal and call center will be available for therapy prior authorization request submissions for dates of service on or after November 1, 2024.

    Place of service settings

    The following place of outpatient service settings (including professional and home) will be included in the rehabilitation program.

    • Outpatient office – POS 11
    • Outpatient independent clinic – POS 49
    • Telehealth – POS 02/10
    • Outpatient Hospital – POS 22
    • Home – POS 12

    Therapy modifiers
    To process your claim correctly, modifiers indicating the type of therapy are required and should be utilized on all evaluation and management and treatment code lines:

    • GP: Physical therapy
    • GO: Occupational therapy
    • GN: Speech therapy

    Exclusions:

    Autism Spectrum Disorder diagnosis will be excluded from requiring prior plan approval. 

About Us

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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