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 has contracted with WholeHealth Living, a Tivity Health company, to administer a registration process for physical medicine services as well as to provide medical necessity review and authorization, where applicable, for these services.

Administrative Guide

Physical Medicine Management Program Administrative Guide
A complete guide for professional and facility providers detailing the requirements of the Physical Medicine Management Program.
Physical Medicine Provider Pathways Program
Guidelines for qualifying professional and facility providers.
Physical Medicine Provider Pathways - FAQs
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

Manipulation

Outcome Assessment Tool

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

Reconsiderations and Appeals

Last updated on 6/1/2023 9:20:21 AM

*This program began on September 1, 2012.

Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.

Quick Links:

Manuals

Highmark Provider Manual

Medical Policy Search Medical Policy Search

Medical Policies

Medicare Advantage Medical Policies

eSubscribe

Requiring Authorization

Pharmacy Policy Search