Therapy Prior Authorization Reminder
Date: 09/27/18
Managed Health Services (MHS) partnered with National Imaging Associates, Inc. (NIA) to ensure that the physical medicine services (physical, occupational, and speech therapy) provided to our Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect members are consistent with nationally recognized clinical guidelines. Effective August 1, 2017, PT, OT and ST services do NOT require prior authorization when provided by a participating provider.
As of August 1, 2017, physical, occupational and speech therapy services claims are reviewed by NIA peer consultants to determine whether the services met/meet MHS’ policy criteria for medically necessary and medically appropriate care. These determinations are based on a review of the objective, contemporaneous, clearly documented clinical records. These reviews help us determine whether such services (past, present, and future) are medically necessary and otherwise eligible for coverage.
Claims should continue to be submitted to MHS for adjudication. All therapy claims must contain the appropriate modifier when submitted to the health plan in order to ensure appropriate adjudication. Failure to include a specialty modifier (GN, GO, GP), may result in the inability to process your claim. Medical necessity denials can be appealed through NIA. All other claims appeals are processed through the health plan.
NIA may request clinical documentation to support the medical necessity and appropriateness of the care. There is no need to send patient records at this time. NIA will notify you if records are needed. If records are necessary, it is important you know that MHS cannot adjudicate your claims until the necessary information is received. If the documentation received fails to establish that care is/was medically necessary MHS may deny payment for services and future related therapy services thereafter. If requested records are not received, claims will be denied due to lack of information.
You will be able to upload requested records on the NIA website www.RadMD.com or through the NIA fax number at 1- 800-784-6864. Medical necessity reviews are based on clinical guidelines which are available on the NIA website at http://www1.radmd.com/solutions/physical-medicine.aspx.
As the nation’s leading specialty health care management company, NIA delivers comprehensive and innovative solutions to improve quality outcomes and optimize cost of care. If NIA therapy peer reviewers determine that the care provided fails to meet our criteria for covered therapy services, you and the member will receive notice of coverage decision.
Please keep in mind you will need to ensure that the member has not exhausted his/her PT/OT/ST benefit and/or has a habilitative benefit prior to providing services. The purpose of NIA is to review medical necessity of PT/OT/ST services, and not to manage the member’s benefits. Please verify member eligibility by utilizing the Indianamedicaid.com website or calling MHS provider Services at 1-877-647-4848.
We appreciate your participation and look forward to your assistance in assuring that MHS members receive Physical, Occupational and Speech Therapy services in a quality, clinically appropriate manner.
Should you have questions, please contact MHS Provider Services at 1-877-647-4848.