Physical Medicine Management Program

To help ensure that outpatient physical medicine services (physical therapy, occupational therapy and manipulation services) provided to our members are consistent with nationally recognized clinical guidelines, Highmark West Virginia has contracted with WholeHealth Networks, Inc. (WHN), a subsidiary of Tivity Health Support, LLC., to administer a registration process for physical medicine services as well as to provide medical necessity review and authorization, where applicable, for these services, effective with dates of service of Sept. 1, 2012, and beyond.

This page will serve as a reference source for providers to learn about the launch and implementation of this program. Check back often as additional information will be added on an ongoing basis.

Learn More About the Physical Medicine Management Program

Communications:

• Medical Doctors, Doctors of Osteopathic Medicine, Doctors of Chiropractic, CRNPs, Physical Therapists and Occupational Therapists
  • Highmark West Virginia to Introduce Physical Medicine Management Program, Effective September 1, 2012
  • Highmark West Virginia To Modify Modalities Operational Guidelines For Physical Medicine Management Program
• Hospital and Skilled Nursing Facilities
  
  • Highmark West Virginia to Introduce Physical Medicine Management Program, Effective September 1, 2012, issued June 15, 2012 
• Physical Medicine Management Program – Important Updates
  
  • Highmark West Virginia's Physical Medicine Management Program began Sept. 1, 2012. As you begin to follow the program, we are committed to providing ongoing updates and the information you need during the Program's implementation. Read important updates and check back often for the most current information

Please continue to look for future communications from us on this topic, and check the Plan Central page of NaviNet and upcoming issues of Provider News for additional tools and information to assist you in the program's authorization process.

Administrative Guide

• Physical Medicine Management Program Administrative Guide (Revised April 24, 2020)
  A complete guide for professional and facility providers detailing the requirements of the Physical Medicine Management Program.

• Physical Medicine Provider Pathways Program (Revised March 2021)
  Guidelines for qualifying professional and facility providers.

• Physical Medicine Provider Pathways - FAQs (Revised April 24, 2020)
  Frequently asked questions for the Physical Medicine Provider Pathways Program.

Reference Materials

The following documents/forms include information that supports the Physical Medicine Management Program; the purpose of each is fully explained in the Administrative Guide above.

• Physical Medicine Care Management Worksheet

Clinical Criteria

• Clinical Criteria - Physical Medicine

Physical/Occupational Therapy

• Utilization Management PT/OT Clinical Decision Support Tools
• Preauthorization Request for Physical/Occupational Therapy
  
  • Preauthorization Request Instructions - Physical/Occupational Therapy

Manipulation

• Utilization Management Clinical Decision Support Tools
• Preauthorization Request for Manipulation Services
  
  • Preauthorization Request Instructions for Manipulation Services

Outcome Assessment Tool

• The Patient-Specific Functional Scale
  
  • Patient-Specific Functional Scale Description

Reconsiderations and Appeals

• WholeHealth Networks, Inc. UM Department Request Form
• Provider Pathway Reconsideration Request Form - Physical/Occupational Medicine
• Provider Pathway Reconsideration Request Form - Chiropractic

Advisory Committee Meeting Minutes

• March 22, 2016
• August 11, 2015
• May 12, 2015
• February 3, 2015
• November 11, 2014
• August 26, 2014
• May 30, 2014
• February 11, 2014
• November 12, 2013
• May 14, 2013
• February 12, 2013
• November 13, 2012