What is OrthoNet’s role in the authorization process?

US Family Health delegated Medical Management and Claim responsibilities for in-network occupational and physical therapy services to OrthoNet.

OrthoNet will receive all requests for additional therapy services, other than the initial visit, and perform utilization review services.

Does the initial evaluation need to be authorized?

Initial therapy visits do not require authorization in this program. However, subsequent visits do require authorization from OrthoNet prior to the patient being treated. Although no longer necessary, OrthoNet recognizes that many providers will still wish to verify eligibility/benefits and authorize the patient’s initial therapy visit.

Please follow the procedures outlined below for requesting additional visits to request an authorization for a therapy initial evaluation. Please make sure that you use an OrthoNet Fax Request Form for all therapy visit requests.

How do I submit a request for additional therapy visits?

A. Complete the Fax Request Form.
Complete the Provider Section on the Master copy initially mailed to you and make clean copies.

In the Therapy Provider Information section provide either the facility name or treating provider name with their corresponding OrthoNet identification 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 Member Information section, fill in the member’s name, date of birth, and USFH 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 date of request, type of service requested, date of initial evaluation, diagnosis, and requested number of visits fields.

B. Submit the Fax Request Form.
Please fax the completed form along with a copy of the completed PT/OT Initial Report Form or its’ equivalent, to OrthoNet’s Medical Management Fax number at 1-800-874-0452. 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 accessing our website at www.orthonet-online.com or by calling OrthoNet’s Provider Services Department at 1-800-401-0062 and a package will be mailed.

C. Receive the authorization number.
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 one (1) business day following the receipt of all necessary information.

Providers will be notified via fax of the authorization number assigned and number of visits approved.

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 for additional visits will be 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.

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 supporting clinical data, verify eligibility/benefits, render a determination and assign an authorization number, if approved, within one (1) business day following the receipt of all necessary information.

How will I find out about the decision?

OrthoNet will fax all decision letters to providers after a decision has been made. These letters will be faxed to the fax number that is on file for each provider. This is why it is especially important for facilities that have more than one location to specify which location on the Fax Request Form. Generally, faxes will be sent to you during the night that the decision was made.

Why do I have to use OrthoNet’s Fax Request Form?

Due to the high volume of requests and updates received daily at OrthoNet, it is imperative that all fax submissions be accompanied by an OrthoNet Fax Request Form. This enables OrthoNet to identify, route, track and review all submissions in a prompt and efficient manner. Submissions without the Form or incomplete forms can not be processed.

Can I treat prior to authorization?

If you treat a patient prior to OrthoNet’s authorization determination, for those visits, please be advised that authorization may not have been given and that those visits might not be eligible for benefits. Should you need to, you may call OrthoNet’s Provider Service Department at 1-800-401-0062 to ascertain the status of a member’s authorization request.

Our authorizations all bear expiration dates. Should you wish to request an extension of an unexpired authorization, please call OrthNet’s Provider Service Department at 1-800-401-0062 prior to the expiration date of the authorization. OrthoNet’s policy is that expiration dates will be extended if calls are received prior to the expiration date as long as it fits within the member’s benefit timeframes.

Where do we submit claims?

Paper claims can be mailed to OrthoNet at the following address:

OrthoNet
Claims Department
P.O. Box 5016
White Plains, NY 10602

OrthoNet can not accept and/or process any faxed claims.

Electronic submissions are accepted using WebMD. You must provide (# 13382) as the Payor identification number. If you have any questions on electronic submissions, you may contact WebMD directly at 1-800-845-6592.

Where do we send claim appeals?

Only those claims processed by OrthoNet are subject to appeal through OrthoNet. Claim appeals can be mailed to OrthoNet at the following address:

OrthoNet
Claims Department
P.O. Box 5054
White Plains, NY 10602

You may also fax the information to OrthoNet’s Correspondence Department at 1-914-949-4929.

What is the claims filing time?

New York Providers have six months (120 days) from the date of service to submit their claims. If a provider wishes to have their claims adjudicated, it must be requested within six months from the last denied or paid date on the claim.

Connecticut Providers have ninety days (90 days) from the date if service to submit their claims. If a provider wishes to have their claims adjudicated, it must be requested within three months from the last denied or paid date on the claim.