CommercialReimbursementMedium impact
00.03.06g, Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Serv
Independence Blue Cross·PM&R (Physical Medicine & Rehab), Physical Therapy, Occupational Therapy·Claims & Billing
Effective date
Oct 1, 2025
We identified it
Jun 19, 2026
Summary
This policy update affects reimbursement for physical medicine and rehabilitation services provided to HMO members by PT/OT providers, with changes to capitation payment structures. The policy is effective October 1, 2025, and applies to commercial HMO and HMO Point-of-Service plans.
Action Required
Before October 1, 2025: Billing team must review contracts with HMO plans to understand which PT/OT services are eligible for reimbursement above capitation rates. Update billing workflows to properly identify and bill eligible physical medicine and rehabilitation services for HMO members. Coordinate with PT/OT providers to ensure proper claim submission processes.