Overview

• Applies to health care professionals in Colorado and Florida who perform physical medicine and rehabilitation (PM&R) services rendered in a physician's office - including most 97xxx CPT codes and HCPC codes G0281 and G0283.
• Applies for members with UnitedHealthcare Choice, Choice Plus, Select, and Select Plus. See the protocol below for more information.
• Does not apply to:
              - Services ordered or rendered by a physician or their staff who have received the UnitedHealth Premium®
                quality and efficiency of care designation (two stars)
              - PM&R services rendered by a network provider with a TIN other than the practitioner's
              - Patients with Medicare and Medicaid coverage. See the protocol below for complete exclusions.
• Submit notifications via fax. Telephone notification submissions will not be accepted.
• Claims payment may be denied if notification is not received.

Objective
This program seeks to improve quality and consistency of care by applying the same notification requirements in place for PM&R services performed in independent PT/OT clinics to those services performed in an office setting.  Our goal is to decrease variance in the delivery of services found in the office setting.  Health care professionals are required to submit a notification to receive reimbursement for most PM&R services. 

The notification includes a brief section completed by the patient containing standard health questions regarding their condition.  This information is used to monitor treatment progress and recommend a number of sessions (visits) to the health care professional until the member reaches their maximum therapeutic benefit or limits as determined by their benefit plan.

This is a prior notification program and not a precertification, preauthorization, or medical necessity determination.

Program Details
Beginning October 9, 2007, health care professionals in Colorado and Florida who perform and bill for PM&R services rendered in a physician’s office are required to submit a notification when those services are performed. 

PM&R services are only eligible for reimbursement when provided by a physician or therapy provider duly licensed to perform those services as described in the applicable benefit plan.  PM&R services rendered by non-licensed individuals who are not duly licensed to perform those services are not eligible for reimbursement, regardless of whether they are supervised by, or billed by, a physician or other licensed therapy provider.

Prior notification will be required for PM&R services billed by physician offices – including most 97xxx CPT codes and HCPC codes G0281 and G0283.  See the CPT code list below for details.  

Please submit PM&R notifications to UnitedHealthcare’s intake center via fax at 1-888-329-5183.  Telephone submissions will not be accepted.

This notification process applies to:

• Physicians and health care professionals at their direction who have designated themselves as practicing in one of the following specialty areas:  anesthesiology, family practice, internal medicine, neurology, orthopaedics, rehabilitation medicine, or surgery.
• Members with UnitedHealthcare Choice, Choice Plus, Select, and Select Plus as noted on the patients identification card.  See the protocol below for more information

This notification process does not apply to:

• PM&R services ordered or rendered by a physician or their staff who have received the UnitedHealth Premium quality and efficiency of care designation (two stars next to their names). View the UnitedHealth Premium page to determine designation status.
• PM&R services performed in hospital outpatient settings.
• PM&R services rendered by a network provider with a TIN different than your own.
• Patients with Medicare and Medicaid coverage
• Physicians outside of Colorado and Florida (additional states to be announced)

See the protocol below for more information, including a listing of products to which this program does not apply.