How to access pelvic floor therapy through an HMO plan

An HMO plan, or Health Maintenance Organization plan, is a type of health insurance that provides coverage through a specific network of doctors, hospitals, and healthcare providers.

How does an HMO plan work?

Think of it as a coordinated care system where everything flows through the primary care physician (PCP). Here's how an HMO plan typically works:

Patients select a PCP from the HMO's list of network doctors
All healthcare needs go through the PCP, who manages the patient's overall care and serves as the healthcare coordinator. If patients need to see a specialist, they usually need a referral from their PCP
Patients must use healthcare providers and facilities within the HMO plan's network (except for emergencies)

How do patients get a referral for pelvic floor physical therapy?

Getting a specialist referral with an HMO involves several steps, and timing is important:

Patient sees their PCP: The PCP will need to refer you to a specialist within the HMO network.
PCP submits the referral order to insurance: The PCP must submit the referral order directly to the patient's insurance company.
Wait for authorization: The insurance company reviews and approves the referral. Patients should not schedule their specialist appointment until they receive this approval.
Insurance company sends authorization details: Once approved, the insurance company should provide the PCP/patient with information such as:
1. An authorization or referral number
2. Start and end dates for the authorization period
3. Number of visits approved
4. Authorized CPT codes (a CPT code is a five-digit code that identifies medical, surgical, and diagnostic services and procedures)
PCP submits the referral to the specialist: The PCP can now submit a complete referral (including the authorization details) to the specialist to initiate care. Providers can refer to Origin Physical Therapy using this form.

Important: The referral must be on file with the patient's insurance company before they see the specialist, or claims may be denied.

What happens if a patient sees a specialist without a proper referral from their HMO plan?

If a patient sees a specialist without a referral that's properly filed with their insurance company, claims will likely be denied. This means the patient could be responsible for the entire bill.

For patients, always confirm that:

Your PCP has submitted the referral to your insurance
You've received authorization details from your insurance
The specialist is in your HMO network

For providers, ensure that:

The referral order has been submitted directly to the patient's insurance company
The patient has received authorization before scheduling their appointment
All required documentation is complete and accurate

Do HMO plans require special approval for physical therapy treatments?

Yes, most HMO plans require pre-authorization for specialized treatments including physical therapy, occupational therapy, and other rehabilitation services. This process should be handled by the PCP.

Why pre-authorization matters: Without proper pre-authorization from the insurance company, any claims that the specialist submits may be denied, leaving the patient responsible for the full cost of treatment.

The PCP's role: The PCP is responsible for initiating the authorization request with the insurance company (by submitting a referral order to the insurance company) before the patient begins treatment.

Important for providers: Pre-authorization is separate from the referral process. The insurance company will need to authorize care before the patient can be seen by the specialist. Always verify the specific requirements with the patient's insurance company.

What if there are questions about HMO plan requirements?

For patients: If you're unsure about your specific HMO plan requirements:

Review your insurance plan documents for specific details about your coverage
Ask your PCP's office for guidance—if they are part of the HMO network, they likely work with HMO plans regularly
Contact your insurance company directly, as requirements can vary between plans

For providers: When working with HMO patients:

Contact the patient's insurance company directly to verify specific referral and authorization requirements
Don't assume requirements are the same across different HMO plans, even from the same insurer

Which insurances are in-network with Origin Physical Therapy?

Origin is in-network with most commercial insurers. Check your coverage based on your location here. If you have further questions, please reach out to our patient services team at info@theoriginway.com.