Outpatient, Physical and Occupational Therapy Providers

48-Unit Benefit Limit in Provider Web Portal

Providers are reminded that members may receive up to 48 units of any combination of physical therapy/occupational therapy (PT/OT) services per rolling 12-month period before a Prior Authorization Request (PAR) is required. Evaluation and orthotic services are not included in this limit. This equates to roughly 12 hours of therapy services (each unit of service being equal to 15 minutes). This unit limit will be automatically enforced by the Colorado interChange by denying claims that exceed the limit.

The Provider Web Portal will display the number of outpatient PT/OT units a member has used in the past 12 months; however, the accuracy of the Web Portal is limited by the timeliness of submitted claims. It should not be relied upon to inform the provider of an absolute number of remaining units. Providers are advised to always seek a PAR at the beginning of a member’s therapy if it is anticipated the member will require more than 48 units of service in a 12-month period.

Beginning September 1, 2020, providers will not be granted a retroactive PAR based on the unit count displayed in the Provider Web Portal.

Contact Alex Weichselbaum at [email protected] with questions.

(Provider Bulletin - Page 5)