Harvard Pilgrim’s physical and occupational therapy payment policy covers one initial evaluation per episode of illness. Harvard Pilgrim denies subsequent initial evaluations performed within 60 days of the original evaluation. Subsequent evaluations may be reimbursed upon appeal under certain circumstances, including:
- Functional therapy is medically necessary for a different condition and a significant change in treatment is necessary
- A member has a new occurrence or exacerbation of a disease/ injury following remission
- A member has surgery for the same or related condition, interrupting or following a course of functional rehabilitative therapy
When filing an appeal, please be sure to include substantiating documentation supporting the necessity of a new evaluation. For more information, please refer to the Physical, Occupational, and Speech Therapy Payment Policy.