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).
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 Rehabilitative 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. This includes the below diagnosis codes:
