EFFECTIVE JULY 1, 2019 The following NEW process will be implemented:

1. PCPs will be the gatekeepers for referrals for PT/OT/ST services. The PCP will provide the initial referral for services to include an evaluation plus treatment visits, for a maximum up to 12. This updates the current referral process of creating a referral for the evaluation only.
2. Subsequent referrals may be processed in increments of a maximum of 6 visits per referral. The benefit maximum for referrals is 30 visits. Therefore, a total of 4 referrals are allowed.
3. If additional visits beyond 30 are clinically indicated, clinical review and approval is required through Total Health Care’s Utilization Department. The provider of service may fax clinical information to 313-748-1312 to request visits beyond 30. The PCP is not required to initiate the request.

NOTE: Chiropractic services are a combined benefit with physical therapy for most commercial members and also require a PCP referral. Therefore, any chiropractic referrals should be deducted from the 30 visits for PT referrals. The PCP will be able to initiate the referral, but it is up to the provider of services to verify eligibility and benefits. Therefore, the referral is not a guarantee of payment.

Click here to read more and learn about the new process in its entirety.