|| June 15, 2012
||Billing Office Personnel
||Care/Case Management/Utilization Review Dept
||Director/Manager of Patient Accounts
||Highmark Blue Cross Blue Shield West Virginia (Highmark West Virginia) Provider Relations
This bulletin announces that Highmark and the Highmark Health Insurance Company (HHIC) have contracted with Healthways WholeHealth Networks to administer a Physical Medicine Management Program affecting manipulation services and outpatient physical therapy and occupational therapy services, effective September 1, 2012.
Since skilled nursing facilities (SNFs) are permitted to bill for outpatient physical therapy and occupational therapy only for their Medicare Advantage patients, the information below applies only to Medicare Advantage business -- specifically to "Part B" situations in which the member has exhausted benefits or is no longer receiving a Medicare skilled level of care in the skilled nursing facility.
Speech therapy services are not included in the Physical Medicine Management Program. In addition, although manipulation services are included in the Program, they will not be discussed in detail in this bulletin.
To help ensure that physical medicine services (physical therapy, occupational therapy and manipulation services) provided to members are consistent with nationally recognized clinical guidelines, Highmark and HHIC have contracted with Healthways WholeHealth Networks, Inc., to administer a registration process for physical medicine services and provide medical necessity review and authorization for these services, where applicable, effective with dates of service on and after September 1, 2012.
This program is being implemented in response to increasing demands from employer group customers for products that promote quality, medically appropriate care and value for their employees. In addition, the goal is to ensure that physical medicine services are clinically indicated and medically necessary, follow established treatment protocols and are in accordance with members' benefit coverage.
Healthways WholeHealth Networks, Inc.
Healthways WholeHealth Networks, Inc. ("Healthways") was founded in 1981 and includes a team of clinical managers, nurse review specialists and clinical peer reviewers. The Healthways Physical Medicine Management Program is accredited by the Utilization Review Accreditation Commission (URAC) and is supported by published, multi-specialty clinical guidelines and more than 20 years of historical claims and authorization data. Its treatment algorithms and protocols are continually reviewed and updated annually by a Clinical Oversight Committee to reflect best-practice clinical outcomes and industry standards.
Products Included in the Physical Medicine Management Program
For SNFs, the Physical Medicine Management Program will apply only to HHIC's FreedomBlue PPO product.
(In provider settings other than SNFs, the Physical Medicine Management Program applies to Highmark West Virginia's commercial health plans, including Super Blue® Plus PPO, Super Blue Select Point of Service (POS), Steel, West Virginia Small Business Plan (WVSBP) and HHIC's FreedomBlue PPO Medicare Advantage Plan. The requirements will be waived for Highmark West Virginia's Traditional Indemnity product, BlueCard® and the Federal Employee Program® members.)
Registration and Authorization Requirements Effective on and after September 1, 2012: An Overview
The Physical Medicine Management Program effective September 1, 2012 involves two key components: registration and authorization.
SNFs that provide physical medicine services must register their Medicare Advantage patients, beginning with their first visit for physical medicine services on or after September 1, 2012. This annual requirement applies to members who already received services in 2012 before the effective date of the Physical Medicine Management Program, as well as to members whose services begin after that date. Once the member is registered, the first eight vists -- for manipulation services or any combination of physical therapy and/or occupational therapy services -- do not require authorization.
Services beyond the initial eight require authorization. The SNF must submit a treatment plan to Healthways for services beginning with the ninth visit. If the treatment plan is approved through the Healthways medical necessity review, an authorization will be provided. If physical medicine services (after the initial eight visits) are provided without an authorization, they will be denied.
The information below applies when the Medicare Advantage member is receiving physical or occupational therapy in a "Part B" situation. Note that this may occur when the member has been in a covered Part A stay, then exhausts benefits or ceases to receive a Medicare skilled level of care. At the point at which the services begin to be provided under the Part B component of the member's Medicare Advantage benefit plan, the provider must register the patient and, as necessary, request authorization of the treatment plan.
SNFs must register all Medicare Advantage members to whom they provide outpatient physical medicine services, starting with their first visit occurring on or after September 1, 2012. This annual requirement applies to members who have already been in treatment on an outpatient basis as well as to new patients. (In calendar year 2012, the registration requirement includes members who received outpatient services prior to the effective date of the Physical Medicine Management Program.)
The member's first eight visits will not require authorization. Note that any previous outpatient therapy services the member may have received in calendar year 2012 before the September 1, 2012 implementation date will be counted toward the eight-visit threshold.
After the member has received eight visits for manipulation services or eight combined physical medicine and/or occupational therapy services, and before the ninth visit, the SNF must submit a treatment plan for authorization.
Submitting Registrations and Authorization Requests/Treatment Plans to Healthways
Under the Physical Medicine Management Program, patient registrations and authorization requests/treatment plans will be submitted to Healthways via a new option within the NaviNet Authorization Submission transaction. Your facility's External Provider Relations representative will contact you to arrange for training and to discuss other options that may be available to you.
The Healthways Medical Necessity Review Process
In the Healthways medical necessity review process, treatment plans/authorization requests submitted by providers are benchmarked against established clinical algorithms. The member's case history is also assessed for potential clinical contraindications and cross-referenced with treatment protocols for specific conditions. As always, SNFs that provide physical medicine services will be notified of updates to existing Medicare Advantage medical policies that will be included in the medical necessity review of their treatment plans and/or the payment of claims. Please refer to the attached list of procedure codes that apply to the program.
The requesting provider will receive a prompt notification about the outcome of the authorization review process. If a treatment plan is not authorized, the requesting provider can request a peer-to-peer discussion of the non-certification decision.
Claims for outpatient physical medicine services performed without the Healthways authorization will be rejected. The member will be held harmless and will not be responsible for payment.
The Physical Medicine Management Program will be implemented for services delivered on and after September 1, 2012. Healthways will begin accepting authorization requests/treatment plans beginning on August 20, 2012.
Additional Tools and Information on the Physical Medicine Management Program
Providers are encouraged to visit the Physical Medicine Management Program page on the Provider Resource Center (under Clinical Reference Materials) for additional tools and information to assist you in the program's registration and authorization processes. Providers should also watch Plan Central for additional information.
Tools to be made available on the Physical Medicine Management Program page include a checklist of information the SNF should be prepared to provide as part of the authorization request/treatment plan submission process.
For questions regarding this bulletin, please contact your assigned External Provider Relations Representative.
Inquiries about Eligibility, Benefits, Claim Status or Authorizations
For inquiries about eligibility, benefits, claim status or authorizations, Highmark West Virginia and HHIC encourage providers to use the electronic resources available to them -- NaviNet and the applicable HIPAA transactions -- prior to placing a telephone call to the Customer Service Center.
Highmark Blue Cross Blue Shield West Virginia is an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association. SuperBlue and FreedomBlue are service marks of the Blue Cross and Blue Shield Association. BlueCard and the Federal Employee Program are registered service marks of the Blue Cross and Blue Shield Association.
NaviNet is a registered trademark of NaviNet, Inc. NaviNet, Inc., is an independent company that provides a secure, Web-based portal between providers and health care insurance plans. Healthways WholeHealth Networks, Inc. is an independent company that provides physical medicine management services. NaviNet, Inc. and Healthways are solely responsible for the products and services they provide and that are referenced in this bulletin.