Changes in prior authorization for Blue Cross NC outpatient therapy requests effective November 1

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:

Training webinars

To help you prepare for this rehabilitation solution, Carelon will host a series of webinar sessions designed for providers and office staff who will be rendering therapy services and requesting prior authorization. Webinar sessions will cover topics such as:

• How the Carelon Rehabilitation Solution works
• For which members and services the rehabilitation solution will apply
• Additional resources
• Q & A

We strongly encourage you and your practice to participate, even if you are already familiar with the Carelon Rehabilitation Solution.

How to register for the webinars
Your facility’s attendance at one of the following training opportunities is highly encouraged. Please register to attend at least one training opportunity. Solution-specific training for Carelon content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training.

How to submit a prior authorization request

• Online: The Carelon provider portal is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. 
• By Phone: Call Carelon toll-free at 866-455-8414, Monday through Friday, between 8:00am - 5:00pm ET.

The Carelon contact center and provider portal will be available beginning on October 21, 2024, for prior authorization requests with dates of service rendered on or after November 1, 2024.

Provider resources

The Carelon Rehabilitation Microsite helps you learn more about the rehabilitation solution and access helpful information and tools.