Healthfirst PT/OT prior auth and coverage changes

Are you a NY PT/OT provider that accepts Healthfirst Medicaid, EP, QHP and Medicare plan types in your office/facility? Then this blog post is for you!

The new changes apply for any DOS 7/29/26 and thereafter.

IMPORTANT! If you are an Out of network provider, please double check with Healthfirst if these new changes apply to your office/facility.

What is new?

  • Additional questionnaire for Adult Physical Therapy requests
  • Adult care will be divided into 2 categories: CHRONIC VS ACUTE care.
  • Initial treatment request – will have a specific # of visits that will not require an auth.
  • If more visits is required- prior authorization will need to be submitted with proper clinical documentation

Adult Acute PT/OT treatment: short term treatment post incident cate

  • Initial # of visits with out an auth- 10
  • Some examples of cases that would fall into this category- post accident, trauma; post operative (within 90) days; post hospitalization (within 60 days) and snf (within 60 days)

Adult Chronic Care: long term or recurring conditions

  • The initial # of visits that do not need an auth is 5 visits
  • Some examples of chronic care treatments would be: flare-up of a previous condition, pain dx related to a chr9nic condition ( osteoarthritis).

Pediatric PT/OT treatment:

  • Initial request will have a 20 no prior auth visit limit.

Prior authorization request needed documents: for initial or continuation of therapy- beyond the initial number of allowed units.

  • Physician order
  • Initial eval
  • Proposed plan of care

Prior authorization request:

  • Use Availity Essentials
  • Complete the provider questionnaire
  • Submit the related clinical documentation

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