The following protocol will apply for Physical Therapy, Occupational Therapy, and Speech-Language Therapy treatment services:

• Benefits are provided for medically necessary Outpatient Therapy Services when ordered by the Member’s personal physician and provided by a licensed health care provider.
• Any treatment involving more than ten (10) visits must have any and all additional visits pre-certified by the treating provider submitting a treatment plan to PhysMetrics for approval.

• Services not documented as necessary and appropriate or classified as experimental or investigational
• Treatment or services for pre or post-employment physicals or vocational rehabilitation
• Any treatment/service caused by or arising out of the course of employment or covered under any public liability insurance
• Non-medical self-care, self-help, any other self-help physical exercise training, or any other related diagnostic testing
• Air conditioners, humidifiers, air purifiers, therapeutic mattress supplies, or any other similar devices and appliances
• Vitamins, minerals, nutritional supplements, or other similar products
• Services identified by PhysMetrics as covered by entities or third parties other than the Plan must be coordinated appropriately and will be reimbursed based on Plan responsibility
• Services are subject to all general provisions, exclusions, and limitations found in plan booklet

• 24 office visits maximum per year
• 10 office visits maximum per month
• $25 copayment per office visit, due & payable prior to treatment
• X-rays must be precertified by PhysMetrics & referred out to a CUSD contracted imaging provider
  • X-rays are not reimbursed to the chiropractor
• MASSAGE THERAPY IS NOT A COVERED SERVICE UNDER THE PLAN & CODES FOR MASSAGE THERAPY WILL NOT BE ACCEPTED

Written precertification is required for the following services before any claims will be paid.  Please call toll-free at 877-519-8839 for precertification for the following services:

• Treatment for Minor Dependents (15 years of age or younger) must be precertified by PhyMetrics. In the case of an emergency or where authorization was unable to be obtained on the first visit, ONLY the first visit will be covered.
• Treatment involving more than (12) visits during the benefit year. After the 12th visit, all services must be precertified by PhysMetrics.
• Additional CPT Codes may require precertification as set forth in the provider fee schedule.

• Any treatment or service not delivered by a PhysMetrics provider within the defined service areas
• Services not documented as necessary and appropriate or classified as experimental/investigational chiropractic care
• Diagnostic scanning, including Magnetic Resonance Imaging (MRI), CAT scan, and/or other types of diagnostic scanning
• Thermography
• Treatment of services for pre-employment or vocational rehabilitation
• Any treatment or service caused by or arising out of the course of employment or covered under any public liability insurance
• Hypnotherapy, behavioral training, sleep therapy, weight problems, education programs, non-medical self-care or self-help, or any other self-help physical exercise, or any other related diagnostic testing
• Air conditioners, humidifiers, air purifiers, therapeutic mattress supplies, or any other similar devices and appliances 
• Vitamins, minerals, nutritional supplements or other similar products
• Anesthesia, manipulation under anesthesia, hospitalization, or any related service
• Massage Therapy
• Juveniles age 15 and under require a referral from PhysMetrics prior to treatment
• Any treatment more than 12 visits requires precertification for additional visits