Physical Medicine

PhysMetrics

Clovis Unified School District has contracted with PhysMetrics to provide its employees and their family members covered by the CUSD Health Plan with Physical Medicine services.

For detailed information regarding covered services for physical therapy, occupational therapy, chiropractic care and speech and language therapy benefits, click here or download the resource flyers available to the right of this page. If you have additional questions, you can contact:

PhysMetrics

877-519-8839

Available Monday-Friday - 8:00AM to 5:00PM PST

Physical Medicine Services

Outpatient Physical Therapy, Occupational Therapy, Speech and Language Therapy Benefits:
Participating Provider	$25 Patient Copayment
Non-Participating Provider	50% of Network Contract Rate after any applicable deductible

The following protocol will apply for Physical Therapy, Occupational Therapy, and Speech-Language Therapy treatment services:

Benefits are provided for Medically Necessary Outpatient Therapy Services when ordered by the Members personal physician and provided by a licensed health care provider.
Any treatment involving more than ten (10) visits must have any and all additional visits pre-certified by the treating provider submitting a treatment plan to PhysMetrics for approval.

Exclusions:

Services not documented as necessary and appropriate or classified as experimental or investigational
Treatment or services for pre or post-employment physicals or vocational rehabilitation
Any treatment or service caused by or arising out of the course of employment or covered under any public liability insurance
Non-medical self-care or self-help, or any other self-help physical exercise training, or any other related diagnostic testing
Air conditioners, humidifiers, air purifiers, therapeutic mattress supplies, or any other similar devices and appliances
Vitamins, minerals, nutritional supplements or other similar products
Services identified by PhysMetrics as covered by entities or third parties other than the Plan must be coordinated appropriately and will be reimbursed based on Plan responsibility
Services are subject to all general provisions, Exclusions, and Limitations found in plan booklet.

Chiropractic Services

Summary of Chiropractic Services
Chiropractic services by Participating Provider	$25 Patient Copayment plus the PhysMetrics contract rate, subject to maximum rates identified in the provider fee schedule.
Chiropractic services by Non-Participating Provider	Plan does not cover treatment provided by out of network providers.

Limitations:

24 office visits maximum per year
10 office visits maximum per month
$25 copayment per office visit, due and payable prior to treatment
X-rays are not reimbursed to the chiropractor; X-rays must be precertified by PhysMetrics and referred to a CUSD contracted imaging provider
CUSD DOES NOT COVER MASSAGE THERAPY. MASSAGE THERAPY CODES WILL NOT BE ACCEPTED

Written precertification is required for the following services before any claims will be paid. Please call toll-free at 877-519-8839 for precertification for the following services:

Treatment for Minor Dependents (15 years of age or younger) must be precertified by PhyMetrics. In the case of an Emergency or where authorization was unable to be obtained on the first visit, then ONLY the first visit will be covered.
Treatment involving more than (12) visits during the benefit year. After the 12th visit, all services must be precertified by PhysMetrics.
Additional CPT Codes may require precertification as set forth in the provider fee schedule.

Exclusions and Limitations:

Any treatment or service not delivered by a PhysMetrics provider within the defined service areas
Services not documented as necessary and appropriate or classified as experimental or investigational chiropractic care
Diagnostic scanning, including Magnetic Resonance Imaging (MRI), CAT scan and/or other types of diagnostic scanning
Thermography
Treatment of services for pre-employment or vocational rehabilitation
Any treatment or service caused by or arising out of the course of employment or covered under any public liability insurance
Hypnotherapy, behavioral training, sleep therapy, weight problems, education programs, non-medical self-care or self-help, or any other self-help physical exercise, or any other related diagnostic testing
Air conditioners, humidifiers, air purifiers, therapeutic mattress supplies, or any other similar devices and appliances
Vitamins, minerals, nutritional supplements or other similar products
Anesthesia, manipulation under anesthesia, hospitalization, or any related service
Massage Therapy
Juveniles age 15 and under require a referral from PhysMetrics prior to treatment
Any treatment more than 12 visits requires precertification for additional visits