Payer rules change by plan, product, delegated vendor, jurisdiction and effective date. The authorization record should identify the policy or criteria source used, the version or access date when practical, and the exact parameters approved.
GOHEALTHCARE PM&R SPECIALTY GUIDE™
PM&R Prior Authorization
Service-specific authorization, payer criteria, submission quality, peer-to-peer readiness, appeals and 2026–2027 interoperability readiness
Developed by Pinky Maniri, Founder & Chief Executive Officer, GoHealthcare Practice Solutions
AUTHORIZATION FOCUS
Therapy, diagnostics, procedures, medical necessity, payer policy, escalation and authorization integrity.
OPERATIONAL FOCUS
Service-specific authorization, payer criteria, submission quality, peer-to-peer readiness, appeals and 2026–2027 interoperability readiness
REFERENCE YEAR
2026 — verify current payer, coding, coverage and regulatory requirements before use.
GoHealthcare Operational Results
98%Company-reported prior authorization approval rate
50 StatesNational prior authorization and utilization-management support
PM&R FocusPhysiatry, rehabilitation therapy, diagnostics, functional outcomes, access and revenue-cycle operations
Company-reported performance. Results vary by client, payer, specialty, documentation quality, benefit design and case mix. No authorization or payment outcome is guaranteed.
Page Contents
Use the links below to move directly to the clinical, payer, documentation, coding, reimbursement, performance and operational sections.
Foundation & Core Guidance
Operations, Controls & Performance
- Policy Control: Verify the Live Rule Before Building the Request
- Authorization Packet Quality Standard
- Determination Reconciliation: Approval Is Not the Finish Line
- CMS Prior Authorization Changes: Separate 2026 Process Requirements From 2027 API Readiness
- Peer-to-Peer, Reconsideration and Appeal: Make Escalation Clinical, Not Emotional
- Prior Authorization KPIs That Matter
- Authorization Audit Standard
- GoHealthcare Clinical Insights
- GoHealthcare Leadership Perspective
- GoHealthcare Prior Authorization Insight
01
Clinical, Coverage, Documentation & Operations
Evidence at a Glance
Operational prior authorization framework for PM&R therapy, EMG/NCS, botulinum toxin, viscosupplementation, testing, behavioral services and injury programs.
| Domain | Summary (verify against current payer policy & date of service) |
|---|---|
| What it is | A service-specific process that verifies the correct benefit, reviewer, criteria, documentation and approved parameters before care. |
| High-risk services | Therapy, EMG/NCS, botulinum toxin, injectable products, advanced testing and selected behavioral/neuropsychological services depending on plan. |
| Documentation driver | The clinical record must answer the payer criteria with dated, patient-specific evidence rather than generic statements. |
| Submission standard | Verify the live policy, build the packet, map the evidence to criteria, submit, track, reconcile the determination and hand off to scheduling/billing. |
| Common failure | Submitting before the clinical evidence or delegated-reviewer requirements are known. |
| Appeal principle | Answer the exact denial rationale with the missing or misinterpreted evidence. |
| 2027 readiness | Prepare structured data and workflows for electronic prior authorization without treating API implementation as a substitute for medical-necessity documentation. |
This page follows the GoHealthcare Clinical Procedure Guide information architecture: evidence first, then clinical and operational requirements, payer and authorization controls, coding/revenue integrity, GoHealthcare insight, case application, FAQs, key takeaways, future outlook and authoritative sources. Verify every payer, coding, regulatory and clinical statement against the controlling source at the point of use.
02
Clinical, Coverage, Documentation & Operations
Executive / Direct Answer
PM&R prior authorization should be managed as a service-specific evidence process. The team must identify the correct benefit and reviewer, translate the clinical record into the payer’s criteria, secure the exact approved scope and prevent date, unit, body-region, drug or site mismatches.
03
GoHealthcare Operational Guidance
Authorization Intake
Start with the exact requested service, diagnosis, body region, laterality, frequency, units or visits, rendering provider, site of service and expected date range. Do not submit a generic request when the payer adjudicates specific codes, disciplines, drugs or units.
Confirm whether the service requires referral, notification, preauthorization, predetermination or another utilization-management process.
GOHEALTHCARE PRIOR AUTHORIZATION INSIGHT — VERIFY THE LIVE RULE BEFORE YOU BUILD THE REQUEST
04
GoHealthcare Operational Guidance
Therapy Authorization
For PT, OT and SLP, identify discipline-specific visit limits, evaluation rules, initial authorization requirements, plan-of-care requirements, progress-note timing, recertification or extension rules and whether visits or units are counted.
Authorization tracking should reconcile approved dates and counts against scheduled and completed visits. The team should start extension requests before the current authorization is exhausted.
GOHEALTHCARE PRIOR AUTHORIZATION INSIGHT — VERIFY THE LIVE RULE BEFORE YOU BUILD THE REQUEST
Payer rules change by plan, product, delegated vendor, jurisdiction and effective date. The authorization record should identify the policy or criteria source used, the version or access date when practical, and the exact parameters approved.
05
Clinical, Coverage, Documentation & Operations
EMG and NCS
Authorization should align the indication, body region, laterality and intended study scope with the payer policy. Obtain relevant history, examination findings, prior testing and the clinical question the study is expected to answer.
Do not rely on a prior authorization alone to establish medical necessity. Coverage and billing rules may depend on the applicable Medicare Administrative Contractor or commercial payer policy.
06
Clinical, Coverage, Documentation & Operations
Botulinum Toxin and Injectable Therapies
Separate the professional procedure authorization from drug or product authorization when the payer does. Confirm diagnosis-specific criteria, prior treatment requirements, dose, frequency, units, acquisition source and specialty-pharmacy or buy-and-bill pathway.
For viscosupplementation and other injectable products, verify product-specific coverage, knee or joint requirements, prior conservative care, frequency and whether the plan restricts preferred products or sourcing.
07
Clinical, Coverage, Documentation & Operations
Behavioral, Psychological and Neuropsychological Services
Determine whether the benefit is managed by the medical plan or a behavioral health administrator. Confirm provider credentialing, testing indications, authorization units and any limits on administration, scoring, interpretation or report services.
Protect sensitive information and transmit only what is necessary under the applicable privacy and payer requirements.
08
Clinical, Coverage, Documentation & Operations
Injury Programs
Workers compensation and auto injury authorization rules are jurisdiction-specific and may involve adjusters, nurse case managers, treatment guidelines, pre-certification vendors, utilization review or legal representatives.
Capture claim number, accepted body part or condition, date of injury, employer or carrier, adjuster, jurisdiction, approved provider and billing instructions before services proceed.
09
GoHealthcare Operational Guidance
Denial Prevention and Escalation
Common failures include wrong benefit manager, missing records, expired authorization, wrong site, unapproved units, missing drug authorization, body-region mismatch and treatment outside the approved date range.
Use a documented escalation ladder for peer-to-peer review, reconsideration and appeal. Preserve the original submission, policy version, evidence sent, decision rationale and all call or portal references.
WATCH-OUTS — HIGH-RISK FAILURE MODE
Do not treat the visible denial or audit finding as the entire problem. Trace the defect to the earliest point where the workflow should have prevented it, then correct that control and re-test.
10
GoHealthcare Operational Guidance
Build a Service-Specific Authorization Architecture
| PM&R Service | Typical Authorization Questions | Operational Evidence to Capture |
|---|---|---|
| PT, OT, SLP | Is evaluation separately permitted? Are visits or units limited? Is an initial authorization, notification, plan of care or progress update required? Which entity manages therapy? | Discipline, dates, approved visits/units, evaluation/treatment distinction, plan requirements, extension rules and utilization remaining. |
| EMG/NCS | Does policy support the indication, body region and study? Are provider qualification or site requirements specified? Is repeat testing restricted? | Clinical question, symptoms/findings, prior testing, requested region, policy criteria, determination and approved scope. |
| Botulinum toxin/chemodenervation | Is the procedure approved separately from the drug? What diagnosis, prior treatment, dose, frequency and product requirements apply? | Procedure authorization, drug authorization, product, dose/units, acquisition path, frequency, prior response and approved dates. |
| Viscosupplementation/injections | Which joint/product is covered? What conservative care or imaging is required? Is there a preferred product or sourcing rule? | Joint/laterality, diagnosis, prior therapies, product, series/frequency, authorization and acquisition instructions. |
| Psychological/neuropsychological testing | Is the service under medical or behavioral health benefit? What testing units and provider credentials are covered? | Referral question, benefit manager, approved services/units, credentialing and report requirements. |
| DME/orthotics | Is a separate supplier or authorization required? Are same/similar or replacement rules relevant? | Item, order, supplier, benefit, authorization, medical-necessity evidence and delivery documentation. |
| Workers' compensation/auto injury | Who controls treatment authorization, what body part is accepted, and what jurisdictional pathway applies? | Claim number, carrier, adjuster, accepted condition/body part, jurisdiction, authorization and communication log. |
GOHEALTHCARE PRIOR AUTHORIZATION INSIGHT — VERIFY THE LIVE RULE BEFORE YOU BUILD THE REQUEST
Payer rules change by plan, product, delegated vendor, jurisdiction and effective date. The authorization record should identify the policy or criteria source used, the version or access date when practical, and the exact parameters approved.
11
Policy, Evidence & Source Guidance
Policy Control: Verify the Live Rule Before Building the Request
The authorization specialist should be able to identify the payer, exact plan/product, utilization-management entity, policy title or portal requirement, policy effective date and date verified. If criteria are not publicly available, document the payer communication or portal response used. Do not build a request from an old screenshot or from what worked for another patient.
Convert the current criteria into an evidence map. Each requirement should point to a specific part of the medical record. If the policy asks for duration of symptoms, failed conservative treatment, objective findings, imaging concordance, functional limitation, prior response or a treatment plan, the submission should identify where that evidence exists instead of sending an undifferentiated chart dump.
When a criterion is not met, the team should not manipulate wording to make the record appear compliant. Escalate the gap to the clinician. The clinician may clarify documentation when clinically accurate, select a different service, continue conservative care, request peer review based on patient-specific circumstances or decide not to proceed.
12
GoHealthcare Operational Guidance
Authorization Packet Quality Standard
A strong request is concise enough for a reviewer to understand and complete enough to support the requested service. The cover summary should identify the requested service, diagnosis, relevant region/laterality, clinical problem, functional impact, prior treatment, objective evidence, prior response where relevant, and the exact attachments that substantiate the criteria.
For therapy, include the discipline, evaluation findings, functional deficits, measurable goals, plan frequency/duration and progress when requesting additional visits. For EMG/NCS, clarify the neurologic question and examination findings. For injected products, reconcile the procedure and product information. For cognitive or neuropsychological services, state the referral purpose and how results will influence management.
Every submission should preserve what was sent, when it was sent, through which channel, by whom, and any portal confirmation or transaction identifier. This is operational evidence. Without it, appeals become reconstruction exercises.
GOHEALTHCARE PRIOR AUTHORIZATION INSIGHT — VERIFY THE LIVE RULE BEFORE YOU BUILD THE REQUEST
Payer rules change by plan, product, delegated vendor, jurisdiction and effective date. The authorization record should identify the policy or criteria source used, the version or access date when practical, and the exact parameters approved.
13
Clinical, Coverage, Documentation & Operations
Determination Reconciliation: Approval Is Not the Finish Line
| Field to Reconcile | Risk If Ignored |
|---|---|
| Service/procedure | A similar but different service may have been approved. |
| Dates of service | Scheduling outside the approval window can create denial. |
| Visits or units | Therapy and testing utilization can exceed approved quantity. |
| Provider/location | Approval may be tied to a rendering provider or site. |
| Body region/laterality | The clinical and claim details may not match authorized scope. |
| Drug/product and dose | Procedure approval may not establish drug coverage; approved units may differ. |
| Frequency/series | Repeat services may require new criteria or a new authorization. |
Structured authorization fields should feed scheduling and pre-bill edits. Do not leave critical approval details only in scanned letters or free-text notes.
14
Policy, Evidence & Source Guidance
CMS Prior Authorization Changes: Separate 2026 Process Requirements From 2027 API Readiness
CMS-0057-F requires certain impacted payers to meet prior authorization process requirements beginning in 2026 for covered non-drug items and services. CMS describes decision timeframes of 72 hours for expedited requests and seven calendar days for standard requests for impacted payers, with specified exclusions, and requires a specific reason when a prior authorization request is denied. Organizations should use the exact rule and payer applicability rather than assuming every commercial plan is governed identically.
Beginning January 1, 2027, certain CMS-regulated payers must implement and maintain Prior Authorization APIs. For PM&R organizations, the practical preparation is not merely “connect to an API.” It is to standardize structured service data, clinical evidence, authorization statuses, determination fields and source traceability so electronic workflows have clean inputs and reliable downstream controls.
Do not treat the 2027 transition as permission to abandon payer portals or manual controls early. Hybrid workflows will persist, and drug authorization remains a distinct area with different rules. The organization should maintain an inventory by payer and service showing which workflow applies and when.
GOHEALTHCARE PRIOR AUTHORIZATION INSIGHT — VERIFY THE LIVE RULE BEFORE YOU BUILD THE REQUEST
Payer rules change by plan, product, delegated vendor, jurisdiction and effective date. The authorization record should identify the policy or criteria source used, the version or access date when practical, and the exact parameters approved.
15
GoHealthcare Operational Guidance
Peer-to-Peer, Reconsideration and Appeal: Make Escalation Clinical, Not Emotional
A peer-to-peer should begin with the denial rationale and the governing criterion. Prepare the physician or qualified reviewer with a one-page clinical brief: requested service, patient-specific problem, objective findings, failed or contraindicated alternatives, functional impact, relevant imaging/testing, prior response, and the exact point of disagreement with the payer.
If the denial reflects missing information, correct the record and resubmit through the proper pathway rather than arguing a criterion that was never addressed. If the dispute is clinical interpretation, explain why the patient's facts satisfy the policy or why an exception is medically appropriate. Preserve the reviewer name, date, discussion, outcome and next appeal rights.
Appeals should be categorized by root cause. A successful appeal does not make the underlying defect acceptable. If a request was denied because the team repeatedly omitted a required therapy progress note, the operational response is to fix the submission checklist and training, not celebrate the overturn.
16
GoHealthcare Operational Guidance
Prior Authorization KPIs That Matter
| Metric | Definition | Management Use |
|---|---|---|
| First-pass approval rate | Approved without avoidable resubmission, peer review or appeal / completed determinations. | Measures request quality; stratify by service and payer. |
| Referral-to-submission time | Time from complete referral to PA submission. | Separates internal delay from payer turnaround. |
| Payer determination time | Submission to determination, excluding documented provider-response delays when appropriate. | Identifies payer/vendor friction and SLA issues. |
| Authorization defect rate | Approvals requiring correction because of wrong scope, dates, units, provider/site or product. | Measures quality beyond approval volume. |
| Expiration leakage | Approved visits/units/services lost because the authorization expired unused. | Connects PA work to scheduling and patient access. |
| Avoidable denial rate | Denials traced to missing, incorrect or untimely internal process elements. | Primary process-improvement target. |
| Appeal overturn rate | Successful reconsiderations/appeals / completed appeals, segmented by reason. | Useful only with root-cause analysis. |
GOHEALTHCARE PRIOR AUTHORIZATION INSIGHT — VERIFY THE LIVE RULE BEFORE YOU BUILD THE REQUEST
Payer rules change by plan, product, delegated vendor, jurisdiction and effective date. The authorization record should identify the policy or criteria source used, the version or access date when practical, and the exact parameters approved.
17
GoHealthcare Operational Guidance
Authorization Audit Standard
Audit complete episodes rather than isolated authorization records. Start with the requested service and compare the live policy used, evidence submitted, determination, scheduled service, clinical documentation, coded service and claim outcome. This is how organizations identify a “successful” authorization process that still produces claim mismatch.
The audit should answer: Was the correct payer/product identified? Was the correct utilization manager used? Was the policy current? Did the clinical record support the request? Was the determination captured accurately? Did the service occur within approved scope? Did changes in the plan trigger a new review? Did the claim match what was authorized and documented?
GOHEALTHCARE PRIOR AUTHORIZATION INSIGHT — VERIFY THE LIVE RULE BEFORE YOU BUILD THE REQUEST
Payer rules change by plan, product, delegated vendor, jurisdiction and effective date. The authorization record should identify the policy or criteria source used, the version or access date when practical, and the exact parameters approved.
WATCH-OUTS — HIGH-RISK FAILURE MODE
Do not treat the visible denial or audit finding as the entire problem. Trace the defect to the earliest point where the workflow should have prevented it, then correct that control and re-test.
18
GoHealthcare Operational Guidance
GoHealthcare Clinical Insights
GOHEALTHCARE CLINICAL INSIGHTS — A DENIAL IS OFTEN THE VISIBLE END OF AN EARLIER DEFECT
The denial letter arrives at the end of the process, but the true defect may have occurred at intake, benefit verification, documentation, policy selection, coding, site-of-service selection or submission. Root-cause analysis should therefore trace backward through the case instead of treating every denial as an isolated payer event.
19
GoHealthcare Operational Guidance
GoHealthcare Leadership Perspective
GOHEALTHCARE LEADERSHIP PERSPECTIVE — BUILD AUTHORIZATION AS A CLINICAL OPERATIONS FUNCTION
Prior authorization performs best when it is neither clerical nor adversarial. It is a structured translation of the clinical record into the criteria used by the payer. Leadership should govern policy sources, submission quality, escalation, authorization-to-claim reconciliation and defect feedback to the clinical and front-end teams.
20
GoHealthcare Operational Guidance
GoHealthcare Prior Authorization Insight
GOHEALTHCARE PRIOR AUTHORIZATION INSIGHT — VERIFY THE LIVE RULE BEFORE YOU BUILD THE REQUEST
Payer rules change by plan, product, delegated vendor, jurisdiction and effective date. The authorization record should identify the policy or criteria source used, the version or access date when practical, and the exact parameters approved.
21
GoHealthcare Operational Guidance
GoHealthcare Case Study / Operational Scenario
Operational scenario. An EMG/NCS request is repeatedly pended because the practice submits the order and diagnosis but not the clinical examination and symptom distribution required by the delegated reviewer. The authorization team adds a service-specific pre-submission checklist and refuses to submit incomplete packets. Turnaround improves because the defect is removed before payer review rather than escalated afterward.
This scenario is illustrative and is not represented as a specific patient case or guaranteed outcome.
22
GoHealthcare Operational Guidance
GoHealthcare Best Practices
- Verify the current authoritative source before operational reliance.
- Define the owner, minimum required data, readiness status and escalation rule.
- Reconcile the clinical record, authorization and final claim before billing.
- Track defects by root cause and feed them back to the workflow that produced them.
- Use AI and automation only within a governed process with human accountability.
GOHEALTHCARE BEST PRACTICES — BUILD THE CONTROL INTO THE WORKFLOW
The strongest PM&R organizations make the correct action easier to perform than the incorrect one. Standard work, structured data, readiness rules, pre-bill reconciliation and visible exceptions reduce dependence on memory and heroic follow-up.
23
GoHealthcare Operational Guidance
Common Mistakes
- Using generic payer rules instead of the patient’s current plan and product.
- Scheduling before all service-specific readiness requirements are complete.
- Allowing authorization, documentation, coding and billing data to diverge.
- Relying on copied or templated language without patient-specific clinical evidence.
- Fixing denials one case at a time without correcting the upstream defect.
24
GoHealthcare Operational Guidance
Pearls and Pitfalls
- Make the clinical purpose of the service unmistakable.
- Capture objective baseline data before measuring progress.
- Start authorization extensions before the existing approval is exhausted.
- Preserve source/version traceability for payer and coding decisions.
- Audit complete episodes periodically, not only individual notes or claims.
25
Clinical, Coverage, Documentation & Operations
Frequently Asked Questions
Does an authorization guarantee payment?
No. Authorization does not override eligibility, benefit limitations, coding rules, medical necessity at claim review, contract terms or other payment requirements.
What should be reconciled after approval?
Approved service/code scope, units or visits, dates, provider, location/site, drug or device parameters when applicable and any conditions.
When should a peer-to-peer be used?
When the case meets the clinical basis for escalation and the reviewer needs physician-level clarification or additional medical-necessity discussion.
What changes in 2027?
Certain impacted payers are required to implement Prior Authorization APIs under CMS interoperability rules. Operational teams still need accurate criteria, documentation and human oversight.
26
GoHealthcare Operational Guidance
Key Takeaways
- A service-specific process that verifies the correct benefit, reviewer, criteria, documentation and approved parameters before care.
- Therapy, EMG/NCS, botulinum toxin, injectable products, advanced testing and selected behavioral/neuropsychological services depending on plan.
- The clinical record must answer the payer criteria with dated, patient-specific evidence rather than generic statements.
- Verify the live policy, build the packet, map the evidence to criteria, submit, track, reconcile the determination and hand off to scheduling/billing.
- Submitting before the clinical evidence or delegated-reviewer requirements are known.
27
Policy, Evidence & Source Guidance
Future Outlook
- Electronic prior authorization will reduce some transaction friction but expose weak data structures.
- Source traceability will become more important as AI and APIs support criteria matching.
- More organizations will measure first-pass approval and avoidable pends by root cause.
- Authorization teams will increasingly operate as clinical-data and exception-management functions.
28
GoHealthcare Operational Guidance
Related GoHealthcare Resources
https://www.gohealthcarellc.com/physical-medicine-rehab-specialty-pmr-hub.htmlhttps://www.gohealthcarellc.com/pmr-specialty-overview.htmlhttps://www.gohealthcarellc.com/pmr-practice-operations.htmlhttps://www.gohealthcarellc.com/pmr-revenue-cycle-management.htmlhttps://www.gohealthcarellc.com/pmr-clinical-documentation.htmlhttps://www.gohealthcarellc.com/pmr-coding-billing.htmlhttps://www.gohealthcarellc.com/pmr-compliance.htmlhttps://www.gohealthcarellc.com/pmr-kpis-performance-metrics.htmlPM&R Specialty HubGoHealthcare MSK Specialty Procedure Library™Prior Authorization Resource CenterRevenue Cycle Management Resource CenterCase Study LibraryElectromyography (EMG)Nerve Conduction Studies (NCS)PM&R Clinical Guidelines
GOHEALTHCARE CODING INTELLIGENCE
Use the dedicated coding libraries for current code-family navigation and crosswalk methodology: PM&R CPT & HCPCS Coding Library, PM&R ICD-10-CM Diagnosis Crosswalk Library, and PM&R Modifiers, NCCI & MUE Reference. The service-specific page remains the controlling operational context.
29
Policy, Evidence & Source Guidance
Guidelines, Standards & Authoritative References
Applicable Guidelines, Coverage Policies and Professional Standards
GoHealthcare separates clinical guidance from coverage policy. A clinical practice guideline helps inform care; an LCD, NCD, billing article, payer medical policy or utilization-management rule determines coverage and administrative requirements for a specific payer, jurisdiction, benefit and date of service. Verify both layers before relying on this page operationally.
| Source | Guideline / Policy Resource | How to Use It Operationally |
|---|---|---|
| CMS | CMS-0057-F | Prior authorization process requirements and 2027 API implementation for impacted payers. |
| CMS | Therapy Services | Medicare therapy thresholds are not interchangeable with MA/commercial authorization requirements. |
| CMS | DMEPOS Prior Authorization | Medicare prior authorization framework for selected DMEPOS items. |
| Medicare Coverage Database | Jurisdiction-Specific LCDs/Articles | Use patient MAC, date of service and current policy version before authorization or billing. |
GUIDELINE CONTROL — DO NOT TREAT A LINK AS THE POLICY
Confirm the current version, effective date, patient payer/product, Medicare Administrative Contractor when applicable, state rules, site of service, provider qualifications and benefit limitations. Retired or superseded policies should remain in the audit trail but should not drive current authorization or billing decisions.
Authoritative sources; verify the current version and effective date before relying on any policy, coding, coverage or clinical requirement.
- https://www.cms.gov/initiatives/burden-reduction/overview/interoperability/policies-regulations/cms-interoperability-prior-authorization-final-rule-cms-0057-f. https://www.cms.gov/initiatives/burden-reduction/overview/interoperability/policies-regulations/cms-interoperability-prior-authorization-final-rule-cms-0057-f
- https://www.cms.gov/priorities/electronic-prior-authorization/overview. https://www.cms.gov/priorities/electronic-prior-authorization/overview
- https://www.cms.gov/medicare/coding-billing/therapy-services. https://www.cms.gov/medicare/coding-billing/therapy-services
- https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms012673. https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms012673
- https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms018912. https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms018912
- https://www.cms.gov/medicare-coverage-database/search.aspx. https://www.cms.gov/medicare-coverage-database/search.aspx
- https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits. https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits
- https://www.cms.gov/medicare/payment/fee-schedules/physician. https://www.cms.gov/medicare/payment/fee-schedules/physician
- https://www.hhs.gov/hipaa/for-professionals/index.html. https://www.hhs.gov/hipaa/for-professionals/index.html
- https://oig.hhs.gov/. https://oig.hhs.gov/
- https://www.aapmr.org/about-physiatry/about-physical-medicine-rehabilitation. https://www.aapmr.org/about-physiatry/about-physical-medicine-rehabilitation
- https://www.apta.org/. https://www.apta.org/
- https://www.aota.org/. https://www.aota.org/
- https://www.asha.org/. https://www.asha.org/
- Centers for Medicare & Medicaid Services. https://www.cms.gov/
- Medicare Coverage Database. https://www.cms.gov/medicare-coverage-database
- GoHealthcare Practice Solutions Knowledge Center. https://www.gohealthcarellc.com/
Build a Defensible, Scalable PM&R Workflow
GoHealthcare supports prior authorization, medical-necessity documentation, payer policy interpretation, coding and revenue integrity, appeals, PM&R operations and AI governance.
Developed By
Pinky Maniri
MSc, BSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance
Founder and Chief Executive Officer, GoHealthcare Practice Solutions
Educational and Operational Disclaimer
This content is provided for educational and operational planning purposes and is not medical, legal, coding, reimbursement or payer-contract advice. Coverage, authorization, coding, payment and clinical requirements vary by patient, plan, product, jurisdiction, Medicare Administrative Contractor, date of service, setting and current policy. Verify the controlling source before scheduling, authorization, billing, appeal or clinical decision-making. Authorization does not guarantee coverage or payment.
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