2017-61: PT, ST & OT Services Update for Providers
Date: 12/01/17
Louisiana Healthcare Connections is partnering with National Imaging Associates, Inc. (NIA) to ensure that the physical medicine services (physical, occupational, and speech therapy) provided to our Louisiana Healthcare Connections members are consistent with nationally recognized clinical guidelines. As the nation’s leading specialty health care management company, NIA delivers comprehensive and innovative solutions to improve quality outcomes and optimize cost of care.
NOTE: Effective March 1, 2018, physical, occupational, and speech therapy (PT, OT and ST) services will NOT require prior authorization when provided by a participating provider. Beginning March 1, 2018, PT, OT and ST services claims will be reviewed by NIA peer consultants to determine whether the services met/meet Louisiana Healthcare Connections policy criteria for medically necessary and medically appropriate care. The following Frequently Asked Questions may assist you in preparing for this transition.
What is the purpose of the review for PT, OT and ST claims?
These determinations are based on a review of the objective, contemporaneous, clearly documented clinical records. These reviews help us determine whether such services (past, present and future) are medically necessary and otherwise eligible for coverage. If NIA therapy peer reviewers determine that the care provided fails to meet our criteria for covered therapy services, you and the member will receive notice of coverage decision.
How will PT, OT and ST claims be submitted?
Claims should continue to be submitted to Louisiana Healthcare Connections for adjudication. All therapy claims must contain the appropriate modifier when submitted to the health plan in order to ensure appropriate adjudication. Failure to include a specialty modifier (GN, GO, GP), may result in the inability to process your claim. Medical necessity denials can be appealed through NIA. All other claims appeals are processed through the health plan.
Is clinical documentation required?
NIA may request clinical documentation to support the medical necessity and appropriateness of the care. There is no need to send patient records at this time. NIA will notify you if records are needed. If records are necessary, it is important you know that Louisiana Healthcare Connections cannot adjudicate your claims until the necessary information is received. If the documentation received fails to establish that care is/was medically necessary, Louisiana Healthcare Connections may deny payment for services and future related therapy services thereafter. If requested records are not received, claims will be denied due to lack of information.
How can requested records be submitted?
You will be able to upload requested records on the NIA website, www.RadMD.com, or submit through the NIA fax number at 1-800-784-6864. Medical necessity reviews are based on clinical guidelines which are available on the NIA website at: www1.radmd.com/solutions/physical-medicine.aspx.
How are member eligibility and benefits verified?
Please verify member eligibility by utilizing the secure provider portal located on the Louisiana Healthcare Connections website, www.louisianahealthconnect.com, or by calling the health plan’s Provider Services team at 1-866-595-8133. Please keep in mind you will need to ensure that the member has not exhausted his/her PT/OT/ST benefit and/or has a habilitative benefit prior to providing services.