PT/OT Q&A for providers

Benefits

Dean Health Plan recommends checking member eligibility via the Provider Portal, but providers can also call Dean Health Plan Customer Service to check, as well.
No, Speech Therapy authorizations will continue to come to Dean Health Plan. Continue to utilize your current process.

Submitting requests

Yes, each person submitting authorization requests needs their own login and password per HIPAA regulation.
Either the physical therapist or office staff can complete authorizations. Please use the NIA Magellan checklist located on RadMD to ensure you have all relevant information before starting the authorization request.
Providers have 10 days from evaluation date to submit both for care registration and authorization. No exceptions will be made.
Dean Health Plan has a daily data file exchange with NIA Magellan so that member information is updated each day.
The average turnaround time is 2-3 business days after all clinical documentation has been received. NIA Magellan has 14 business days to make a determination, but the average is 2-3 business days.

Visits

If providers choose to provide PT/OT treatment on the same day as the evaluation without receiving an approved authorization first, it is not guaranteed that the services will be covered by Dean Health Plan. It is
always recommended that providers first receive the approved authorization before performing treatment.

Again, if the therapy is found to not be medically necessary, then the therapy would not be covered, but the evaluation would be covered.

Providers do not have to do the authorization until after the evaluation is completed. If there are no follow-ups after the evaluation, the provider will be paid for the evaluation.
Yes, you will need to call NIA Magellan’s Customer Service number if you need to update/change a current authorization. If it is a new episode of care, a new authorization will need to be submitted.
Members have eight total care registration visits per calendar year, regardless of service type. All additional visits require authorization.

No, PT/OT benefit counters renew when the insurance policy renews. Therefore, it is important to first check the member’s benefits prior to submitting the authorization request. For example, some of our members’ policies renew in July, therefore all of their benefit counters reset on their policy renewal date in July. This differs from care registration, as care registration resets on Jan. 1 for all members.

NIA Magellan PT/OT Fax Number: 800-784-6864

Yes, we would be asking you to provide the evaluation notes and progress notes if you are requesting more than the eight visits.
If the patient has two PT visits in one day by the same provider (i.e. same billing information), Dean Health Plan counts this as one visit in the member’s benefit count. If the services differ, for example if the patient has
one PT visit and one OT visit on the same day, this would count as two separate visits in the member’s benefit count.
All authorizations are end-dated for Dec. 31, so the provider needs to log in to NIA Magellan to complete a care registration for services on and after Jan. 1 of the next calendar year.
If the validity period is ending and the patient hasn’t used all of their visits, the provider will need to call NIA Magellan’s Customer Service number to extend the validity period.
Services will need to have prior authorization; if providers provide services without an authorization and the authorization is denied, Dean Health Plan will not cover those services. Again, if additional visits are needed, call NIA Magellan’s Customer Service number. NIA Magellan may request clinical documentation to support the need for additional visits.
Dean Health Plan’s guideline on LATs has not changed. If you have specific questions regarding how you utilize LATs or would like a copy of our policy on the use of LATs, please reach out to your Provider Network Liaison for assistance.
If a patient has an additional diagnosis that includes a separate body region from their authorization, an additional authorization is required.
If both providers are part of the same group and submit claims with the same billing information, a separate authorization is not necessary.
If the care registration was completed for physical therapy, but occupational therapy will be used to treat a different body part, it is a separate instance of care and occupational therapy would need a separate (new) prior authorization. For example, if care registration is completed for physical therapy for body part A, but occupational therapy is later needed for body part B, then the provider would need a new separate authorization for body part B.