Remember these important BCBSM physical therapy updates, tips

As a physical therapist, it’s important that you follow certain protocols. We’ve included some helpful reminders and updates for you to keep in mind.

Reconsideration of category assignment

Reconsideration of category assignment is a clinical oversight process to review factual or objective data that focuses on:

• Extreme, difficult or surgical cases
• Unique situations
• Additional episodes of care

You may request reconsideration:

• When your category assignment moves from category A or B, into category C
• By calling the Landmark Customer Service number at 1-877-531-9139
• Within 14 days of the Landmark categorization letter date stating the change

Reconsideration will not be an option if you have been placed in category C three or more consecutive times, as it gives no time to promote change. All information will be reviewed during the appeal process if requested.

The scope of the reconsideration is limited to documenting additional episodes. Additional episodes must fall within the same reporting period. Each reporting period contains 12 months of claims detail and is designated by the month and year in which the period ends. For example, the July 2012 reporting period includes claims from
Aug. 1, 2011, to July 31, 2012.

The episode may be:

• For a different body part
• Initiated following surgery
• Following a significant event, such as an auto accident

An episode of care is all physical therapy treatment provided to a member for a body part or related body part within a given 12-month period. Members who receive treatment for conditions for two distinct body parts within a reporting period may have two episodes.

Note: Waxing and waning of symptoms are not considered additional episodes.

Review of outlier cases
An outlier is a patient who requires higher intensity and duration of services. When working with an outlier patient, keep in mind:

• Documentation must demonstrate medical necessity for the services provided. You should review the clinical documentation before requesting the removal of a patient from the data to assure the patient and chart meet these criteria.
• Once information has been provided and reviewed, additional information will not be accepted.
• You must identify all outliers prior to starting the analysis.

Proper diagnosis for BCBSM claims
The primary diagnosis on the BCBSM claim is used to identify the body part being treated. The claims used for categorization include only the primary diagnosis and do not include any secondary diagnosis in relation to treatment. Please note:

• If treatment extends beyond the initial primary diagnosis or if additional treatment is equally primary, then you need to document the additional diagnoses at least once in the primary diagnosis field during the course of treatment.
• Due to the volume of reconsiderations, only the results will be shared. Final category affiliation decisions are subject to an appeal process.
• When you request a reconsideration, you must send data to Landmark and follow these requirements:
  • Once the reconsideration is requested, providers have 14 days to submit their information.
  • All information must be submitted at the same time.
  • All outliers must be identified at the time information is submitted.

BCBSM notification and recourse
Once you have been in category C for three consecutive categorization periods, you will receive notification from Blue Cross Blue Shield of Michigan. The purpose of this notification is to alert the provider to comply with network standards to avoid a disaffiliation notification.

A disaffiliation notification is a network termination notification that will be sent to all providers in category C for four consecutive categorization periods. At this time a provider may request a first level appeal through BCBSM if he or she doesn’t agree with the notification, or the provider can voluntarily withdraw from the network.

Appeal process
If you don’t agree with the disaffiliation notification, you can appeal it. You have two levels of appeals, they include:

• First level appeal: After the Blues review your first appeal, you’ll be notified if it’s pended, overturned or maintained and the appropriate steps you’ll need to take.  
• Second level appeal: This is your final opportunity to appeal your notification of disaffiliation. The Blues will determine if your second level appeal will be overturned or maintained.
• Instead of a second level appeal, you may voluntarily withdraw from the network.

If you’re disaffiliated, you must follow these steps:

• You must notify your patients that you’re no longer in the BCBSM PPO network.   
• You may treat a BCBSM member; however the member’s copay and deductible will be higher. You must clearly communicate this to the member.
• You must wait two years before you can reapply to the network, and you must meet the criteria to be accepted.

Billing reminders for credentialed physical therapists
Therapists who are credentialed as both outpatient physical therapists and independent physical therapists may not practice as an IPT out of their OPT facilities. An IPT can work out of an OPT facility, but must bill under the facility and not on a professional claim. Once you’re identified as a credentialed therapist, your provider representative will meet with you to discuss compliant billing practices.

For more information, call Deb Marvay at 313-448-8219, Blue Cross Blue Shield of Michigan, or call the Landmark Customer Service department at 1-877-531-9139.