Physical Medicine Management Program

To help ensure that outpatient physical medicine services (physical therapy, occupational therapy and manipulation services) provided to our members are consistent with nationally recognized clinical guidelines, Highmark has contracted with WholeHealth Networks, Inc. (WHN), a subsidiary of Tivity Health Support, LLC., to administer a registration process for physical medicine services as well as to provide medical necessity review and authorization, where applicable, for these services, effective with dates of service of Sept. 1, 2012, and beyond.

Learn More About the Physical Medicine Management Program

Communications:

• Medical Doctors, Doctors of Osteopathic Medicine, Doctors of Chiropractic, CRNPs, Physical Therapists and Occupational Therapists
  • Highmark to Introduce Physical Medicine Management Program, Effective September 1, 2012
  • Highmark To Modify Modalities Operational Guidelines For Physical Medicine Management Program
• Hospital and Skilled Nursing Facilities
  
  • Highmark to Introduce Physical Medicine Management Program, Effective September 1, 2012, issued June 15, 2012 (Facility Bulletin search keyword: physical medicine) 
• Physical Medicine Management Program – Important Updates
  
  • Highmark's Physical Medicine Management Program began Sept. 1, 2012. As you begin to follow the program, we are committed to providing ongoing updates and the information you need during the Program's implementation. Read important updates and check back often for the most current information

Please continue to look for future communications from us on this topic, and check the Plan Central page of NaviNet, Today’s Messages on the Provider Resource Center and upcoming issues of Provider News for additional tools and information to assist you in the program's authorization process.

Administrative Guide

• Physical Medicine Management Program Administrative Guide (Revised April 24, 2020)
  A complete guide for professional and facility providers detailing the requirements of the Physical Medicine Management Program.

• Physical Medicine Provider Pathways Program (Revised November 2018)
  Guidelines for qualifying professional and facility providers.

• Physical Medicine Provider Pathways - FAQs (Revised April 24, 2020)
  Frequently asked questions for the Physical Medicine Provider Pathways Program.

Reference Materials

The following documents/forms include information that supports the Physical Medicine Management Program; the purpose of each is fully explained in the Administrative Guide above.

• Physical Medicine Care Management Worksheet

Clinical Criteria

• Clinical Criteria - Physical Medicine

Physical/Occupational Therapy

• Utilization Management PT/OT Clinical Decision Support Tools
• Preauthorization Request for Physical/Occupational Therapy
  
  • Preauthorization Request Instructions - Physical/Occupational Therapy

Manipulation

• Utilization Management Clinical Decision Support Tools
• Preauthorization Request for Manipulation Services
  
  • Preauthorization Request Instructions for Manipulation Services

Outcome Assessment Tool

• The Patient-Specific Functional Scale
  
  • Patient-Specific Functional Scale Description

Reconsiderations and Appeals

• WholeHealth Networks, Inc. UM Department Request Form
• Provider Pathway Reconsideration Request Form - Physical/Occupational Medicine
• Provider Pathway Reconsideration Request Form - Chiropractic

Advisory Committee Meeting Minutes

• March 22, 2016
• August 4, 2015
• May 5, 2015
• February 3, 2015
• November 4, 2014
• August 18, 2014
• May 6, 2014
• February 4, 2014
• November 19, 2013
• May 7, 2013
• February 5, 2013
• November 6, 2012