Prior Authorization and Codes

Providers must submit PARs for medically necessary services when services will exceed 48 units of service per 12-month period.

Submission:

PARs are approved for up to a 12-month period (depending on medical necessity determined by the reviewer).

• Retroactive PAR request forms will not be accepted.
• Overlapping PAR request dates for same provider types will not be accepted, with the exception of Early Intervention PAR requests which may have overlapping dates of service and multiple provider types. All Early Intervention PT/OT PARs must additionally indicate that the member has an Individual Family Service Plan (IFSP) and that it is current and approved.
• Only one PAR for Early Intervention outpatient PT/OT may be active at a time.
• A maximum of one PAR for Early Intervention outpatient PT/OT and one PAR for non-Early Intervention outpatient PT/OT may be active at any time for children ages 0 - 3.
• Overlapping Early Intervention and non-Early Intervention outpatient PT/OT PARs will only be accepted if the treatment plans associated with each meet different goals and use different treatments.
• Incomplete, incorrect or insufficient member information on a PAR request form will not be accepted.

Submit PARs for the number of units for each specific procedure code requested, not for the number of services. Modifier codes must be included. The same modifiers used on the PAR must be used on the claim, in the same order.

• When submitting Rehabilitative Therapy PARs, and subsequent claims, CPT codes for PT services must have the GP modifier and the 97 modifier (e.g. 97110+GP+97). CPT codes for OT services must have the GO modifier and 97 modifier (e.g. 97110+GO+97).
• When submitting Habilitative Therapy PARs, and subsequent claims, CPT codes for PT services must have the GP modifier and 96 modifier (e.g. 97110+GP+96). CPT codes for OT services must have the GO modifier and 96 modifier (e.g. 97110+GO+96).
• Early Intervention PARs, and subsequent claims, must have the GP or GO modifier plus the TL modifier (e.g. 97110+GP+TL).

Additional Limitations:

• Members may have one active PAR for each type of therapy (Rehabilitative PT, Rehabilitative OT, Habilitative PT, and Habilitative OT) with independent time spans. These PARs may not overlap in time span unless one of them is for Early Intervention.
• Evaluation and orthotic services do not require a PAR.

PAR Requirements:

• Legibly written and signed ordering practitioner prescription or approved Plan of Care, to include:
• • diagnosis (preferably with ICD-10 code), and
  • reason for therapy, and
  • the number of requested therapy sessions per week, and
  • total duration of therapy.
• The member's Physical or Occupational treatment history, including current assessment and treatment. Include duration of previous treatment and treating diagnosis.
• Documentation indicating if the member has received PT or OT under the Home Health Program or inpatient hospital treatment.
• Current treatment diagnosis.
• Course of treatment, measurable goals and reasonable expectation of completed treatment.
• Documentation supporting medical necessity for the course and duration of treatment being requested.
• Assessment or progress notes submitted for documentation, must not be more than 60 days prior to submission of PAR request.
• If the PAR is submitted for services delivered by an independent therapist, the name and address of the individual therapist providing the treatment must be present in field #24 of the PAR.
• The billing provider name and address needs to be present in field #25 on the PAR.
• The Health First Colorado provider number of the independent therapist must be present in PAR field #28.
• The billing provider's Health First Colorado number must be present in field #29 of the PAR.
• Early Intervention PT/OT PARs must additionally indicate that the member has an Individual Family Service Plan (IFSP) and that it is current and approved.
• DME products cannot be requested on the same PAR as therapy services.

The authorizing agency reviews all completed PARs and approves or denies, by individual line item, each requested service or supply listed on the PAR. PAR status inquiries can be made through the Online Provider Web Portal and results are included in PAR letters sent to both the provider and the member.