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• Introduction
• Provider Expectations
• Utilization Review Procedure

Utilization Review / Precertification Procedures

PRE-CERTIFICATION IS REQUIRED ON THE FOLLOWING:

• Physical/Occupational Therapy - Before services begin
• Chiropractic Services - Before services begin
• Surgery (Inpatient/Outpatient) - Two weeks prior to scheduled surgery date
• Hospital Admissions - Scheduled and Emergency (beyond the first 24 hours)
• Pain Management - Before services begin

RE-CERTIFICATION IS REQUIRED ON THE FOLLOWING:

• Physical/Occupational Therapy - Before services continue either for an extension of the end date or for additional services
• Chiropractic Services - Before services continue either for an extension of the end date or for additional services
• Pain Management - Before services continue either for an extension of the end date or for additional services

In order to be able to process the request for service, please submit the following:

1. Physician Orders
2. ICD9 Code(s)
3. CPT Code(s)
4. Start Date / Admit Date
5. Frequency and Duration of Treatment(s) / Anticipated Length of Stay
6. Therapy / Chiro Notes after Initial Evaluation or Status Report on Re-certification

Please note: Any visits or CPT codes NOT pre-certified will NOT be reimbursed.

In addition, please remember that a certification has two (2) components, the number of visits approved and the start and end date of the approval. If treatment needs to extend beyond the end date, an extension of the end date MUST be requested on or prior to that date.

THE MANAGED CARE UNIT

Telephone: (203) 678-0127
Toll Free: (800) 506-2655
Fax: (203) 269-2198

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