Ask EviCore: Retrospective Therapy Requests
What Should I Know About Retrospective Prior Authorization Requests for Physical Therapy, Occupational Therapy, and Speech Therapy?
Hello! I’m Mark Tate, and my team’s goal is to make the provider experience with EviCore easier, faster, and more collaborative. In this first Ask EviCore of 2021, our topic is retrospective prior authorization requests – authorization requests with a start date more than 7 days in the past. We’ll answer a few questions about the need for retrospective requests for physical therapy, occupational therapy, and speech therapy, and we’ll provide helpful tips if you need to submit a retrospective request.
As always, our objective is to help our provider partners understand the prior authorization process so we can better work together to ensure your patients get the medically appropriate care they need.
Why should I get prior authorization in advance instead of obtaining a retrospective authorization?
Although some health plans allow therapy providers to obtain retrospective authorization, not all do. Generally, retrospective authorizations are discouraged as they place the provider at higher risk for delayed payment, or at risk of a denial of services that have already been provided.
Are there situations when submitting a retrospective request is appropriate?
While obtaining prior authorization approval at the time of therapy is preferable, there may be situations where the therapy provider is unable to do so. One example is when the patient provides incorrect information about their health plan, so you’re unaware that prior authorization is necessary before therapy treatment. Another example is if the patient’s primary payer changes while they’re receiving care, and you are not made aware prior to the change (e.g., in a Worker’s Compensation denial).
If I do need to submit a retrospective request, what’s the best way to do so?
If you are in a situation where submitting a retrospective prior authorization request is necessary, first verify that the patient’s health plan allows retrospective requests. If so, then you can submit the request via EviCore’s web portal or via fax, as you would a typical prior authorization request. You are strongly encouraged to submit the retrospective request via the web portal so you can upload additional documentation at the time of submission. Please also see the question below that provides a list of the information that should be included.
If a health plan allows providers to submit retrospective requests for prior authorizations, what are some tips for submitting this type of retrospective request?
First of all, you are strongly encouraged to submit the retrospective request via the web portal, so you can upload the additional documentation outlined in this answer.
If the treatment start date you requested is more than 7 days in the past, it’s considered a retrospective request. Please submit the following information for retrospective review of medical necessity of this request:
1. The specific dates of service and the number of units for each date of service for which you are requesting retrospective authorization.
2. The initial evaluation and any available progress notes, re-evaluations, and discharge summaries. Please also include functional outcomes scores.
3. Therapy daily notes for each date of service for which you are requesting retrospective authorization.
My patient needs ongoing service. Is that covered under a retrospective request?
If you need prior authorization for ongoing services that have not already been rendered, please submit a separate prior authorization request, just as you would for a new patient who needs therapy treatment.
How do I know if a service I provided is eligible for retrospective prior authorization?
Allowing retrospective prior authorizations depends on the patient’s health plan and their specific policies. Please contact your Regional Provider Engagement Manager and they will provide you with a link to that information.
We really appreciate your engagement with our Ask EviCore series. In fact, many of our 2020 articles were Top Blog Posts for the year. In case you missed them, you can read them here, or search “Ask EviCore” on the Insights tab for previous topics.
If you’d like to ask a question in future editions of the Ask EviCore column, or share your feedback about our prior authorization process, email Jackie Jenkins, the National Provider Advocate on my team, at providernewsletter@evicore.com. Thanks for your ongoing partnership with EviCore. Together, we can ensure your patients get the best possible medically appropriate care.