Prior authorization changes for rehabilitative and habilitative services — training available

This is to inform you about new legislation signed into law in June 2023 — P.L. 2023, c. 275 (L.D. 1383), enacted 24-A MRSA §4304-A.The new law affects prior authorization (PA) requirements for rehabilitative or habilitative services, including but not limited to physical therapies (PT), occupational therapies (OT), and speech therapies (ST).

Beginning with dates of service on or after October 25, 2023, no PA is required for the first 12 rehabilitative or habilitative visits for new episodes of care for Anthem Blue Cross and Blue Shield (Anthem) Commercial members. A new episode of care is defined by the law as treatment for a new condition or treatment for a recurring condition for which a member has not been treated within the previous 90 days. PA will be required starting with the 13th visit and all additional visits per episode of care.

Medicare Advantage and Medicare Supplemental plans are excluded.

Medical necessity review

In implementing this new law, Anthem will transition medical necessity review of therapy services for Anthem Commercial members from the standard Carelon* Rehabilitation Solution to the Carelon QuickCare Rehabilitation Solution for dates of service on or after October 25, 2023. QuickCare will apply to PT, OT, and ST.

Within the QuickCare program, no authorization will be required for the first 12 PT/OT/ST visits within a member’s episode of care. An episode of care will begin when an evaluation or re-evaluation code is billed for a member. These modifiers indicating the type of therapy are required to process your claim correctly:

• GP — Physical Therapy
• GO — Occupational Therapy
• GN — Speech Therapy

This will allow us to identify the correct episode of care so the claim will process correctly. Modifiers also allow us to decrement the correct benefit accumulator as many members have a limit on therapy services under their benefit. Claims without a modifier will reject for lack of information.

QuickCare training webinars

To help you prepare for this program, we’re hosting a series of webinar sessions that are designed for care providers and office staff who will be rendering therapy services and requesting prior authorization.

Webinar sessions will cover topics such as:

• How the Carelon QuickCare Rehabilitation program works.
• To which members and services the QuickCare Rehabilitation Solution will apply.
• Demonstration of the Carelon provider portal and how to enter order requests.

We strongly encourage you and your practice to participate, even if you are already familiar with the Carelon Rehabilitation Solution and the provider portal through other health plans or specialty programs.

How to register for the webinars

Please register to attend at least one training opportunity. Your facility’s attendance at this Carelon training opportunity is highly encouraged. Carelon solution specific training 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.

QuickCare rehabilitation solution webinar sessions
Date	Meeting information
Wednesday, October 11, 2023 Noon ET	Registration link: October 11, 2023
Wednesday, October 18, 2023 Noon ET	Registration link: October 18, 2023
Wednesday, November 1, 2023 Noon ET	Registration link: November 1, 2023

How to submit a request for review

• Online: The Carelon provider portal is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to providerportal.com.
• By phone: Call Carelon toll-free at 866-714-1107, Monday through Friday, 8 a.m. to 5 p.m. ET.

Resources for your practice

The Carelon Rehabilitation website helps you learn more about the QuickCare Rehabilitation Solution and access helpful information and tools:

• Order entry checklist
• FAQs

For more information

• Online: To learn more about Carelon, please visit carelon.com.
• By phone: Contact Provider Services at 833-690-2936 or your Provider Relationship Management representatives.

We look forward to working together to achieve improved outcomes.