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Good Morning
6:31:56 AM CDT
Sunday, April 26, 2015

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Physical & Occupational Therapy
Prior authorization guidelines are applicable for all therapy services. General guidelines include:
  • One initial window period is allowed for claim, inclusive of all accepted body parts and diagnoses
  • Physical therapy and occupational therapy are allowed separate window periods
  • Changing therapists during the course of treatment does not start a new window period
Therapy Window Period
  • Initial window period is 10 treatments (includes the initial evaluation) or 60 days of care, whichever comes first
  • Post-surgical (inpatient or outpatient) window is 10 visits or 60 days, whichever comes first
    • Treatment must start within 90 days after the surgery date
  • Post-manipulation window period is 10 treatments or 60 days, whichever comes first
  • Modalities are limited to two per visit
  • Prior Authorization is required for treatment extending beyond the window
Submitting a Prior Authorization Request for Therapy Services
  • Access Claim Lookup to obtain claim number or status
  • Review the Utilization Review Guide to determine if prior authorization is required
  • Complete the UR-C form
  • Fax UR-C form and supporting documentation to: 701-328-3765 or 866-356-6433
Submitting a Prior Authorization Request for Independent Exercise Program or Work Hardening/Conditioning
  • Access Claim Lookup to obtain claim number or status
  • Review the Utilization Review Guide to determine if prior authorization is required
  • Complete the C59a form for independent exercise requests
  • Complete the C59b form for work hardening/conditioning requests
  • Fax the C59a and/or C59b form and supporting documentation to: 701-328-3765 or 866-356-6433

For more information about services requiring prior authorization, please contact WSI Utilization Review Department at 701-328-5990 or 888-777-5871.

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