Dear Providers,
Now that BCBSNC has moved the effective date of its prior authorization (PA) program for physical therapy (PT) services to December 1st, HNS has received several questions about what that means for coverage of mechanical traction (97012) and unattended electrical stim (97014), as well as other related coverage questions.
To address many of those questions, HNS would like to highlight the following key points:
- Fully Insured BCBSNC Commercial Plans Will Cover 97012 & 97014 Through 11/30/2024
Because the effective date of the PA Program has been moved, BCBSNC fully insured commercial plans will continue to cover mechanical traction (97012) and unattended electrical stim (97014) through 11/30/2024, and thus, you must submit claims to BCBSNC for those services from now until DOS 11/30/2024 and may not bill the patient directly for them. Beginning with DOS 12/1/2024-the new effective date of the program-those services will be considered non-covered for fully insured plans, and as long as you have an appropriately signed non-covered services waiver, you may bill the patient directly for those services starting with services rendered on that date.
- Coverage of 97012 & 97014 by Non-Fully Insured BCBSNC Commercial Plans
After the new PA program goes into effect on 12/1/2024, as we know, it only applies to BCBSNC fully insured commercial plans. As such, for any plan that is not a BCBSNC fully insured commercial plan, mechanical traction (97012) and unattended electrical stim (97014) will continue to be covered as normal. Thus, unless you specifically obtain a written verification of benefits from such a plan, which complies with HNS policy and proves that these services are not covered, you must always file claims for these services and may not bill the patient directly, even if you have a non-covered services waiver. For the avoidance of confusion, FEP, SHP, and all self-funded plans, that HNS is aware of, will continue to cover these services.
- HNS Providers Are Required to Continue to Submit Claims for Covered Services
Importantly, HNS contracted providers must continue to appropriately submit claims for all covered services for all BCBSNC patients, even if their plan is subject to this new PA program. With the exception of certain requests for restrictions of disclosure of health information, there is no general insurance waiver that providers may obtain that will allow them to avoid this requirement. Please see the following policy for more information: https://healthnetworksolutions.net/index.php/election-not-to-file-entf-forms
- Billing of PT Services Denied as Not Medically Necessary
The above being said, and as previously indicated, if the PA program ultimately determines that a PT service or a visit with PT services is medically unnecessary and no further PA will be authorized, those impacted services would be considered non-covered and may be billed to the patient if an appropriate non-covered services waiver is obtained prior to the treatment being performed and is on file in the patient’s healthcare record. For more information on the proper procedure for billing patients for non-covered services, please consult HNS’ Non-Covered Services Policy found here: https://healthnetworksolutions.net/index.php/non-covered-services
For more information about the forthcoming BCBSNC Physical Therapy Prior Authorization Program, please:
the Most Recent Version of the
BCBSNC Physical Therapy Authorization Summary Sheet
Sincerely,
HNS