Rehabilitation Therapy Precertification Requirements

Rehabilitation Therapy Precertification Requirements for Extended Care Facilities

Effective January 1, 2012, the following processes apply for physical, occupational and speech rehabilitation therapy services for members who are confined in an extended care facility. For members who exhaust their skilled nursing benefit or are not eligible for skilled nursing level of care, precertification is required for rehabilitation therapy services. The guidelines vary according to the member's plan as described below.

HMO Commercial/PPO/HMSA QUEST Members

For rehabilitation therapy services ordered by a physician, please review the criteria for coverage in HMSA's physical, occupation and speech therapy policies in the Provider E-Library:

• Cognitive Rehabilitation Therapy
• Occupational Therapy
• Physical Therapy
• Pulmonary Rehabilitation
• Speech Therapy Services/Rehabilitation

Obtain precertification before rendering services or submitting a claim. The facility must submit a complete treatment plan including an evaluation and therapy goals. The evaluation should indicate the results of past therapy, if applicable. Requests for precertification will be reviewed by HMSA staff according to the HMSA policies references above.

HMSA Akamai Advantage® Members

HMSA will cover rehabilitation services without precertification up to the Medicare financial cap for outpatient therapy. Information about financial therapy caps can be found in the following at: https://www.cms.gov/Medicare/Billing/TherapyServices/index.html.

Precertification is required for services exceeding the therapy cap. If additional services are approved, these services must be billed using the KX modifier. Please submit a complete treatment plan including evaluation and continued therapy goals. The evaluation should indicate the results of past therapy. Requests for precertification will be reviewed by HMSA staff according to Medicare guidelines. Members cannot be billed for services that do not meet these guidelines.

Precertification

To precertify, complete HMSA's Precertification Request [PDF] and mail or fax the form and all applicable documentation, including the signed and dated written order from the treating physician, to:

HMSA - Medical Management
P.O. Box 2001
Honolulu, HI  96805

Fax: 808-944-5611 on Oahu

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