Changes for Therapy Services Effective January 1, 2021

Date: 10/29/20

Outpatient Physical Medicine Services (Physical, Occupational and Speech Therapy)

Effective January 1, 2021, outpatient physical medicine services (physical therapy, occupational therapy and speech therapy) will be reviewed for prior authorization by NIA for Ambetter from Sunflower Health Plan.

• PRIOR AUTHORIZATION REQUIRED: Ambetter remains committed to ensuring that physical medicine services provided to our members are consistent with nationally recognized clinical guidelines. Therefore, beginning January 1, 2021, prior authorization of outpatient physical medicine services will be required for Ambetter membership.
• Under terms of the agreement between Ambetter and NIA, Ambetter will oversee the NIA Physical Medicine Prior Authorization program and continue to be responsible for claims adjudication.
• Providers can obtain prior authorization via the NIA website or 1-844-518-9505.
• Please ensure that the member has not exhausted his/her benefit prior to providing services, even if an “Approved Authorization” has been obtained. The purpose of NIA is to verify medical necessity of physical medicine services, and not to manage the member’s benefits.
• The NIA call center will be open to receive prior authorizations effective December 14, 2020, for DOS January 1, 2021, and beyond.

NIA Provider Resources - All health-plan approved training/education materials are posted on the NIA website, www.RadMD.com  

For new users to access these web-based documents, a RadMD account ID and password must be created.  To get started, simply go to www.RadMD.com, click the New User button and submit a “Physical Medicine Practitioner” Application for New Account. Once the application has been processed and a password link delivered by NIA via e-mail, you will then be invited to create a new password. Links to the approved training/education documents are found on the My Practice page for those providers logged in as a Physical Medicine Practitioner.

NIA Provider Training Communication will be shared on the Sunflower Health Plan website Provider Training information click here.

Ambetter and NIA look forward to working with you to ensure that the Ambetter from Sunflower Health Plan members receive physical medicine services delivered in a quality, clinically appropriate fashion.

If you have questions about this bulletin or other provider resources, please contact Ambetter Customer Service at 1-844-518-9505.