What’s my benefit for physical and occupational therapy?
HMSA covers short-term physical and occupational therapy which has been diagnosed and ordered by a physician, physician’s assistant, or advanced practice registered nurse and provided by a qualified provider of services. Therapy can usually be completed within 90 days, or the amount of visits necessary to improve or restore the ability to perform activities of daily living, such as getting dressed, getting in and out of bed, and going to the bathroom. Therapy beyond this is considered long term and isn’t covered by HMSA. Therapy must be necessary to significantly improve function due to a congenital condition or to restore function lost or impaired due to an illness or injury. Significant improvement is defined as a measurable and meaningful increase in the level of physical and functional abilities.
Maintenance therapy, or therapy which helps you maintain your functional level and prevent regression, isn’t covered by HMSA. Moreover, your HMSA therapy benefits aren’t designed to restore you to the level of physical or sports activity you had before your illness or injury, nor do they include care for chronic conditions.
I understand my therapy services may require precertification. How does that work?
To ensure that the physical and occupational therapy services you’re ordered to receive are appropriate and are a benefit of your plan, your therapist must first make a precertification by completing a treatment plan and submitting it to Landmark Healthcare, a company HMSA has partnered with, for review and approval.
Who is Landmark?
Landmark is a company that’s been providing and managing physical and occupational therapy services for health plans and employer groups for more than 25 years. Landmark’s expertise is in reviewing the appropriateness of therapy services in light of your benefits. Landmark is accredited by URAC, which is an independent organization that reviews operational policies and procedures that ensure safeguards for consumers, providers, and employers.
What happens if my therapist isn’t an HMSA participating provider?
If you go to a nonparticipating provider, you’ll have to notify your provider of HMSA’s precertification requirements. It is up to you or your provider to submit the precertification request to Landmark. You may call HMSA Customer Relations for more information.
What if my therapist wants me to have more visits than are authorized?
Your therapist may submit a request to Landmark for additional visits. However, if these additional visits are denied by Landmark, you’ll be responsible for payment for visits that exceed the number of visits that have been authorized.
How do I know if additional visits are authorized?
Whenever Landmark receives a request for authorization for more visits, both you and your therapist will be notified when your request has been approved or denied.
What happens if my claim is denied by HMSA?
It depends on whether or not you or your therapist submitted a precertification request to Landmark.
If you or your therapist submitted a precertification request for additional visits and the visits weren’t approved, you’ll have to pay for them yourself or file an appeal with HMSA.
If you or your therapist didn’t request precertification from Landmark, your therapist can submit a request to Landmark to review these visits for retrospective authorization. If authorization isn’t granted and your therapist is an HMSA participating provider, you’ren’t responsible for paying for these visits. If your therapist isn’t an HMSA participating provider, you’ll have to pay for these visits or file an appeal with HMSA.
How do I file an appeal?
Either you or your HMSA provider may file an appeal with HMSA. In your appeal, you’ll need to provide any additional information that you believe supports your request for these services.
I have Medicare as my primary insurance and HMSA as secondary. Will HMSA cover additional visits after my Medicare benefits have been exhausted?
If you need more visits after you meet the Medicare cap, your therapist must use the Medicare exception process to certify the medical necessity of additional visits. HMSA, as a secondary payer, won’t pay for additional visits if Medicare denies additional therapy. We’ll continue to coordinate benefits with Medicare for covered therapy as appropriate.
If my HMSA plan is secondary to another carrier, does my therapy still require precertification?
Yes. If your HMSA plan is secondary to another carrier, your therapist will still need to submit a precertification request to Landmark. Currently, the secondary claim will deny without precertification.
Whom do I call for more information?
Please call HMSA Customer Relations.