Current Payment News

July 2023

APTA 2023 State Medicaid Payment Rate Guide

The Hub : Forums : APTA 2023 State Medicaid Payment Rate Guide Now Available

July 2022

Federal / CMS Payment Update:
Public Health Emergency Declaration extended to October 13, 2022:

Proposed 2023 Outpatient Payment Rule Presents Advocacy Opportunity: New ruling provides
interesting potential for PT advocacy related to pain management as well as opportunity for improved
payment structure for rural/critical access hospitals. For more information click below.

Commercial Insurer Payment Update:
Elevance (formerly known as Anthem): Instances have been reported by providers that NH/ME claims
were not being processed due to not obtaining prior authorization, however there was no mechanism in
place to obtain prior auth or providers were informed that no auth was required. Elevance has
acknowledged the error and reports facilities will not need to re-process claims.  Unfortunately, they
have not clarified how to determine what is a true denial vs an error on their end. Additionally, Dry
Needling codes will not be covered after June 12, 2022. More information at: Provider Communications

United Healthcare (UHC): APTA continues to request policy updates regarding 97530 and 97140 coding

Medicare and Retirement
 Policy:  Rebundling and NCCI Edits, Professional - Reimbursement Policy -
UnitedHealthcare Medicare Advantage (
Per UHC: If you are seeing denials on these code pairs for the MA or retirement
plans, please provide claims examples to show what denials are occurring so UHC
can research to determine if there is an issue.

 Policy:  Rebundling Policy, Professional - Reimbursement Policy - UnitedHealthcare
Commercial Plans ( ;  CCI Editing Policy, Professional -
Reimbursement Policy - UnitedHealthcare Commercial Plans (

Community and State
 Policy: CCI Editing Policy, Professional and Facility - Reimbursement Policy -
UnitedHealthcare Community Plan (

                                   Per UHC: Without any examples it’s difficult to research what is going on. If there is any example you can provide, please do so and IUHC can dig deeper.

Because we are hearing of issues with the edits in all claims submitted to UHC
Community plans as well as denials under the UHC Medicare Advantage Plan, please
share redacted examples of UHC reimbursement issues to Gerriann Samowski, APTA NH
Payment Chair



May 2022
APTA NH Payment/Reimbursement Update

  • IRF/SNF Fed Reg Rules- IRF appears will get 2% increase in payment and SNF pay cut of 4.6% but market basket update will offset most so will be more of a .7% cut total

  • IP/OP/HC Fed Reg Rule changes coming soon. Scheduled in July, stay tuned

  • CMS Telehealth has extended per the PHE with 5-month extension beyond the end of PHE. PHE renewed until 7/15/22 and with extension will bring it until 12/15/22.  Congress must act at that time and APTA hopes to get permanent extension for PT’s.  This does not include PTA sequestration.  Sequestration will stop once the $ is met but no known date.

    • LBP NCD references dry needling as acupuncture and now commercial payers putting in policies. APTA wants dry needling in PT guidelines not as acupuncture
  • APTA At Work for Profession with AMA survey shows that many are still experiencing delays in payment; AMA is considering a  lawsuit to target abuses.
  • Cohere roll out has been quiet.
  • NIA/Magellan-Aetna-Centene Ambetter plans from 3/16/22 working well. Roll outs will be sent in advance and will work together to set up education.
  • UHC/UHC CCP moving away from paper to electronic claims submission by June 1
    • OPTUM LBP and PT first program to decrease opioid use has moved from the pilot phase to general implementation.  However, uptake on the part of employers to participate in the program has been minimal.  As UHC promoted the program in 2020 during the height of the pandemic,  APTA asked to revisit.
    • 97140/97530 pairing edit and time in/time out for each CPT code.  APTA says unreasonable and is addressing.
    • Habilitation  needs to be prescribed by physician but those states with Direct Access are fighting this. NH does not appear to be impacted.
  • Aetna looking at the 180-day evaluation policy. APTA working to change policy as may have 2nd diagnosis unrelated.  Aetna says in that case they will allow if medically necessary but is not written.
        • 97530 and 97535 same date code pair will be overturning if denied.  No denials should be seen after April.
  • Anthem dry needling no longer covered as of June 12,2022. APTA sent a  letter to challenge the decision  and awaits a response from AIM. Providers can send comments/ references supporting dry needling to the AIM Providers may send comments to  Please be aware that AIM will not reflect your comments or input in this version of the guidelines.
  • Noting payers are trying to become providers to control expenses and to advance value-based efforts.  This needs to be monitored. Integrated Health Systems and Virtual Programs. Some are calling it Virtual PT Programs which APTA and the chapters will address.

Please visit then click on the “Your Practice” tab at the top, then click on the “Payment” tab for more information on these and other payment areas of interest.


APTA NH PO Box 459
Tolland, CT 06084
(857) 702-9915