Frequently Asked Questions : Physical and Occupational Therapy
Providers > Physical Therapy >FAQS

How do I know if my patient has coverage for physical or occupational therapy?

Contact Prism ’s Customer Service Department to verify the patient’s eligibility at the time of initial visit and prior to rendering services. Your patients can also check with their insurance carrier or member handbook to determine whether their benefit plan has any specific requirements, limitations or exclusions for therapy services.

What does my patient need in order to obtain therapy services?

Most health plans require the patient to obtain a written referral and/or prescription from a qualified provider. “Qualified” providers are defined by state and/or federal law, and may also be specified by the patient’s health benefit plan. Patients should obtain necessary referrals and/or prescriptions prior to scheduling an appointment for therapy services. If the referral or prescription expires, the patient may be required to obtain a new one. Once all necessary information has been obtained, the treating therapist submits an appropriate claim to Prism for approval and/or payment of therapy services.

In general, what conditions or services do NOT qualify for therapy coverage?

Services obtained without a valid referral or prescription

• Services that are not medically necessary
• Services outside the practitioner’s scope of practice
• Services that have not been proven effective
• Conditions or diseases where therapy is contraindicated
• Investigational and /or experimental services or treatment
• Maintenance, Preventive or Wellness Care

Does Prism have licensed therapists on staff?

Yes. Prism employs Clinical Peer‑Reviewers who hold unrestricted licenses and registrations to practice physical or occupational therapy. Each Clinical Peer‑Reviewer (“CPR”) has a m inimum of five (5) years experience and has been appropriately trained in the principles, procedures, and standards of Prism. Prism’s CPRs are available to speak with practitioners during regular business hours to discuss the facts of a case. In addition, if an urgent situation exists regarding a member’s treatment, Prism’s Clinical Director can be reached 24 hours per day.