Foot Orthotics (CPB 0451, reviewed 2026-07-16)

By August 16, 2026: Billing team must implement the following controls in billing software and claim submission processes: (1) Verify all foot orthotic claims include prescriber credentials (physician, NP, podiatrist, or qualified health professional per state law) and that provider is licensed/certified (ABC, BOC, or state-licensed); (2) For custom-fabricated orthotics, require documentation explaining why prefabricated alternatives cannot meet member needs—attach to claim or reject; (3) Ensure diabetic shoe claims document one of six qualifying foot complications (deformity, pre-ulcerative calluses, history of ulceration, peripheral neuropathy with callus, poor circulation, prior amputation); (4) Enforce annual limits for diabetic members: either 1 custom-molded shoe + 2 inserts OR 1 depth shoe + 3 inserts per calendar year; (5) Verify diabetic shoes meet material/construction specifications (leather/equivalent, full-length heel-to-toe filler minimum 3/16" depth, full shoe closure); (6) Flag prosthetic shoe claims separately—these are covered even under plans excluding orthotics; (7) Reject claims for deluxe shoe features (color, style) not contributing to therapeutic function; (8) Route all claims through prior authorization workflow if plan requires it. Providers must include physical examination documentation demonstrating orthotic will improve mobility/ADLs and be prescribed within 6 months of provision. Failure to obtain required documentation and certifications will result in automatic claim denials.