Physical/occupational therapy
Prior authorization
National Imaging Associates (NIA) administers the WellFirst Health authorization program for providers.
This program applies to members who are treated by a WellFirst Health-contracted provider as well as all non-contracted providers who have been authorized to provide physical medicine services (some account exclusions apply).
Program details:
- The member’s initial eight visits (inclusive of the evaluation visit) within each plan year will require a care registration authorization.
- If additional treatment (beyond the initial eight visits) is anticipated, prior authorization is necessary and should be submitted just prior to the ninth visit. Authorization requests should be submitted through the Rad MD web portal within 10 days of evaluating your patient for additional care.
- Authorization for treatment will be based on WellFirst Health standards for medical necessity and is a requirement for reimbursement.
- NIA only approves the medical necessity of the services. Note that any of the benefit limitations will apply to any services that are authorized as medically necessary.
- Members who require the services of a provider who is not a WellFirst Health Network provider will require two authorizations:
- WellFirst Health approval to use the non-plan provider
- NIA approval of the medical necessity of the services (if the visits are beyond the initial eight visits)
If there isn’t a prior authorization…
Practitioners who perform services without a prior authorization may experience claim denials. Providers can only bill the member for these services if the member completed a standard waiver form that your office uses and if WellFirst Health does not allow payment for these services.
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