PT/OT Authorizations: Frequently Asked Questions

  • Q1. Initial therapy evaluation does not require an authorization. Is authorization required for re-evaluations?

    A1.Yes. Re-evaluations require an authorization. The re-evaluation codes of 97164 and 97168 as well as the old codes of 97002 and 97004 will be included in the group bundled codes (PT001 and OT001). Home service would be covered in codes PT-S9131, OT-S9129 and ST-S9128.

  • Q2. What are group codes?

    A2.Group codes are sets of codes that encompass multiple codes for PT and OT for each type of therapy. Authorization requests should include the group code PT001 for PT requests and OT001 for OT requests.

  • Q3. What codes are covered under PT001 and S9131?

    A3.The covered codes are:

    • 97002
    • 97164
    • 97012
    • 97014
    • 97034
    • 97018
    • 97010
    • 97024
    • 97032
    • 97124
    • 97110
    • 97022
    • 97113
    • 97116
    • 97762
    • 97140
    • 97112
    • 97530
    • 97761
    • 95992
    • 97035
    • 97150
    • 97760
    • 97016
    • G0283

  • Q4. What codes are covered under OT001 and S9129?

    A4.The covered codes are:

    • 97004
    • 97168
    • 97014
    • 97016
    • 97018
    • 97022
    • 97010
    • 97032
    • 97034
    • 97035
    • 97110
    • 97024
    • 97124
    • 97140
    • 97150
    • 97530
    • 97112
    • 97535
    • 97537
    • 97760
    • 97761
    • 97533
    • 97762
    • G0283

  • Q5. What if I need to submit for a code that is not on this list?

    A5.You should list the code separately on your authorization request. Please note that any codes not included in the bundle will be sent to a clinical/medical director for review.

  • Q6. What if the member needs both PT and OT services?

    A6.You must submit two separate authorization requests, one for PT001 and one for OT001. For home services, use PT- S9131 and OT-S9129.

  • Q7. Do the group codes apply to claims as well?

    A7.For PT and OT, PT001 and OT001 apply only to authorization requests, not claims. You should file claims listing each procedure code individually. For home services, the codes do apply to claims.

  • Q8. How do I submit requests for prior authorization?

    A8.All authorization requests should be submitted online using our Utilization Management Request Tool on NaviNet. To access this tool, simply sign in toNaviNetand from the Horizon NJ Health plan central page and select Utilization Management Requests.

  • 九方。如果我没有获得NaviNet呢?

    A9.If you don’t have access to NaviNet, you cansign up for free. If you cannot submit online, call1-800-682-9094and follow the prompts.

  • Q10. Where can I find training for the online authorization tool in NaviNet?

    A10.到李rn more about using our Utilization Management Request Tool, review the material at教育材料的供应商.

  • Q11. What should I do if NaviNet is down?

    A11.If there is an issue specific to NaviNet, please call NaviNet at1-888-482-8057. If you can access NaviNet but are having issues with the Utilization Management Request Tool application, please emailCareAffiliate@HorizonBlue.com.

  • Q12. Do I need to provide clinical documentation with an authorization request?

    A12.Yes, all clinical documentation needs to be attached for all authorization requests.

  • Q13. What is required clinical documentation once the evaluation/re-evaluation and previous therapy visits have been completed?

    A13.You can include: an updated plan of care, therapist notes and/or re-evaluations containing subjective, objective and functional outcome data which justify the need for skilled services. Dated and signed office notes or daily treatment flow sheets are considered acceptable proof.

  • Q14. How do I submit clinical documents?

    A14.When submitting onNaviNetthrough the Utilization Management Request Tool, you can attach the documents. The tool can accommodate various file types such as PDF, JPG, etc.

  • Q15. How can I check the status of my authorization request?

    A15.You can check status through the Utilization Management Request Tool. Go toNaviNet, under Utilization Management Requests, click on Status. You can check for the authorization status by reference number, provider number or member ID number.

  • Q16. What is the turnaround time for processing a pre-service non-urgent request?

    A16.The turnaround time is 14 calendar days once all required documentation is received.

  • Q17. How long do I have for timely submission of an authorization request?

    A17.You have six calendar days from the date of service to submit your authorization request.

  • Q18. Are the authorized visits required to be within a certain time frame?

    A18.是的,时间框架将包含在approval authorization letter and in the Utilization Management Request Tool onNaviNet.

  • Q19. What if all the visits are used before the end date of the authorization?

    A19.A new request should be submitted for additional visits. Submit the new authorization request viaNaviNetthrough the Utilization Management Request Tool.

  • Q20. If I am a participating provider, can any of my therapists provide services to Horizon NJ Health members?

    A20.No, each provider must be credentialed to provide service to our members.

  • Q21. How do I get credentialed?

    A21.Review the information on theJoin our Networks page.