What is OrthoNet’s role in the authorization process?

OrthoNet is responsible for utilization management for out of network physical and occupational therapy services for CIGNA members. As part of its responsibilities OrthoNet will be performing prospective and retrospective reviews for therapy services.

Do out of network therapy services require prior authorization?

CIGNA does not require prior authorization of out of network physical or occupational therapy services. However, many out of network providers have asked to have the ability to have a pre-determination made on the medical necessity of proposed therapy services. Effective 4/1/2011, prospective review to make a determination of medical necessity will be available. Keep in mind that in accordance with the member’s policy, all therapy services must be medically necessary in order to be a covered benefit.

How can a provider ensure that the therapy services will be approved as medically necessary?

Following the initial evaluation, providers can submit supporting clinical documentation to OrthoNet for a prospective review of medical necessity (see question XX below). Claims submitted for out of network therapy services that were not prior authorized may be subject to retrospective medical necessity review. If a claim is received for out of network services that were not prior authorized and it is selected for medical necessity review, the provider will be contacted by both CIGNA and OrthoNet and informed of the steps to take for the retrospective medical necessity review process.

What is a Prospective Review?

It is the voluntary prospective review process allows providers to submit a request to OrthoNet prior to the delivery of therapy services. The purpose of a prospective review is to have a determination of medical necessity made prior to the therapy services being delivered.

Does the initial evaluation need to be authorized?

Initial therapy visits do not require prior authorization in this program. However, any subsequent visits may be subject to medical necessity review.

How do I request a Prospective Review?

The provider should submit all relevant clinical notes along with the OrthoNet Therapy Fax Request Form to fax# 888-779-8365. The form is available via OrthoNet’s website www.orthonet-online.com., or by contacting the Provider Services Department at 866-874-0727.

How will I be notified of the determination?

After services are reviewed, a letter will be sent to your office as well as to the member with the results of the medical necessity review.

What will OrthoNet need to render a decision on my request?

In order for OrthoNet to promptly respond to your request, current objective clinical data needs to be supplied. Examples of objective clinical data include, but are not limited to: strength, active range of motion, functional status, short and long term treatment goals, and a treatment plan.

This information may be supplied on OrthoNet’s PT/OT Initial Report Form, Functional Progress Chart, or on your own forms or clinical notes that would supply the same information.

Who will be reviewing my request?

Your request will be initially reviewed by a licensed rehabilitation professional. Furthermore, OrthoNet has board-certified physicians and professionals that are experienced in the areas of orthopedics, neurology, pediatrics and sports medicine that also may be part of the review process.

When will the decision be made?

OrthoNet understands the importance of the continuity of care for patients receiving rehabilitation services. In order to maintain this continuity, OrthoNet’s goal is to review the request and any supporting clinical data, verify eligibility/benefits, render a determination and assign an authorization number, if approved, within 2 business days following the receipt of all necessary information.

How do I submit a prospective request for determination of medical necessity for therapy visits?

A. Complete the OrthoNet Out of Network Therapy Fax Request Form.

In the Therapy Provider Information section provide either the facility name or treating provider name with their corresponding NPI or Tax ID number. Also, to identify offices with multiple locations, please complete the address, city, state, and zip fields of the location where the member is to be treated. In the Patient Information section, fill in the member’s name, date of birth and the member’s CIGNA identification number. Please fill in the fields from left to right. In the Request Information section, darken the appropriate request type circle and complete the request type, service type, date of initial evaluation, and diagnosis, code.

B. Submit the Fax Request Form.

Please fax the completed form along with a copy of the initial evaluation or any progress notes and current, objective clinical data (i.e., strength, active and passive range of motion, functional capabilities, etc.) that address both the Member's response to therapy and the progress made towards outlined goals to OrthoNet’s Medical Management Fax Server at 1-888-779-8365. Please submit only Fax Request Forms and any associated documents to this number. If you do not have any Fax Request Forms they may be obtained by accessing our website at www.orthonet-online.com or by calling OrthoNet’s Provider Services Department at 1-866-874-0727 and a package will be mailed to you.

C. Receive the Determination.

It is OrthoNet’s goal to review the request and supporting clinical data, verify eligibility/benefits, render a determination and assign an authorization number, if approved, within 2 business days following the receipt of all necessary information. Providers will be notified via fax on the day of the decision with approval status and the number of visits approved. This document will include your CIGNA Authorization number which is needed for claims submission.

What is a Retrospective Review?

A retrospective review of the medical necessity of services already delivered may be conducted following the receipt of a claim for those services. If a claim is received for out of network services that were not prior authorized and it is selected for medical necessity review, the provider will be contacted by both CIGNA and OrthoNet and informed of the steps to take for the retrospective medical necessity review process.

What is the process for a Retrospective Review?

After receiving the claims from CIGNA for therapy service that were not prior authorized, OrthoNet will mail a letter to the provider’s office requesting clinical documentation supporting the medical necessity for the specific dates of service listed on the claim. This documentation should be sent to OrthoNet.

The provider may fax the requested information to fax# 888-286-8041 or mail it to: OrthoNet/CIGNA Out of Network Review, P. O Box 5009, White Plains, NY 10602.

Where do we submit claims?

Claims are submitted directly to CIGNA at the following address indicated on the member’s identification card.