We’re pleased to announce our new collaboration with OrthoNet, LLC.
August 18, 2015
Starting November 1, 2015*, OrthoNet will handle the management of both in-network and out-of-network outpatient physical therapy and occupational therapy services [in California]. OrthoNet is a musculoskeletal management company that has ties to leading therapists in Anthem’s service areas. It also has created many best practices followed throughout the industry.
Here’s what this new relationship means to your clients. This program consists of a utilization management program.
The Utilization Management program will affect your clients who have the following health plans:
Local fully insured Large Group, Small Group, and Individual products for both public and private exchange business including:
- PPO
- TRAD
Here’s what remains the same
The first time members get an initial evaluation from a physical or occupational therapy provider as an outpatient, they do not need to get prior authorization (prior authorization is also referred to as prior approval or precertification). A member’s current physical and occupational therapy benefit will not change as a result of this new arrangement, as long as the therapy is medically necessary. Getting prior authorization will not affect the member’s access to the care he or she needs.
Here’s what changes
Starting November 1, 2015*, after the initial evaluation as an outpatient, members will be required to obtain prior authorization from OrthoNet for all physical and occupational therapy services for the services to be covered.
- If the member’s plan requires referrals to get coverage for physical and occupational therapy services, the member will still need to get a referral before starting any therapy sessions.
- After the initial evaluation, if the member is using a provider in the network, the provider must get prior authorization for the outpatient physical and occupational therapy services. The provider must send OrthoNet a treatment plan with clinical data for review. This will help make sure that the therapy services are medically necessary, so they will be covered by the health plan. If the member’s in-network provider does not get prior authorization, the member’s benefits may be reduced or denied. But the member will not be held financially responsible for a denial that occurs, if the Anthem participating provider fails to get the prior authorization.
- If the member has benefits to use a provider out of the network or outside of Anthem’s service area, the member should make sure the provider will get the prior authorization from OrthoNet for them, or if the member should do it. The member must make sure that he or she receives prior authorization for the sessions to be covered by their plan. And just like in the past, the member will have to pay that provider any portion of the fee that the plan does not cover.
How we’re communicating this
We’re sending communications to employers, members and network providers telling them about the changes that go into effect November 1, 2015*.
Anthem and OrthoNet are committed to working together to provide our members with access to the services they need. If you have any questions, contact your dedicated Anthem Sales Team.
*The implementation date is subject to the approval of the Department of Managed Health Care.