Anthem home-setting therapy pediatric speech and OT coverage: limits
By Javier Alvarez · Updated · 1 min read
1 row: Anthem (Elevance Health). Public policy, not the member's benefits.
Anthem home-setting therapy
Clinical Guideline CG-REHAB-12, Rehabilitative and Habilitative Services in the Home Setting · All states
| Where it applies | Covers PT, OT and speech-language pathology given in the home. Services are medically necessary when the plan's therapy criteria and the home health criteria are both met. [1] |
|---|---|
| Visit limits | Benefit plans may include a maximum number of visits or duration for therapy. When the maximum is used up, coverage ends even if medical necessity criteria are met. [1] |
| Also | Habilitative services develop skills that have not developed as expected. The guideline gives therapy for a child who is not walking at the expected age as an example. Benefit availability and state mandates should be checked before applying the criteria. [1] |
What Anthem home-setting therapy's documents say
The table above has every field we found for Anthem home-setting therapy, with numbered sources. In short:
- Visit limits. Benefit plans may include a maximum number of visits or duration for therapy. When the maximum is used up, coverage ends even if medical necessity criteria are met.
- Where it applies. Covers PT, OT and speech-language pathology given in the home. Services are medically necessary when the plan's therapy criteria and the home health criteria are both met.
Pediatric speech and OT coverage at other national payers
Aetna (commercial), UnitedHealthcare (commercial and individual exchange) and TRICARE (speech therapy and occupational therapy).
Check Anthem home-setting therapy's claim against the row
Before the claim goes out, compare it with the row above: the evaluation and treatment codes are ones the policy lists, the plan of care and any prior authorization cover the date, and the visit count fits the limit. The pediatric speech and OT table compares Anthem (Elevance Health) with every other payer we checked.