Friday, 10 August 2012

How to get Authorization from OrthoNet for Physical Therapy and Occupation therapy for Empire WellChoice members living in state of New York and New Jersey?

Empire WellChoice has delegated to OrthoNet medical management responsibilities for physical and occupational therapy services for HMO, HMO/POS, PPO, EPO, Child Health Plus and certain ASO account members in the New York and New Jersey regions..

We need to submit the therapy request form to OrthoNet and need to fill the below information. Its need to be fax #1-866-800-7485

Therapy Provider Information
  • Facility Name
  • Provider First Name
  • Provider Last Name
  • Street Address
  • City
  • State
  • Zip
  • Telephone Number
  • Fax Number
  • Provider ID Number
Patient Information
  • First Name
  • Last Name
  • Member ID Number
  • Date of Birth
Request Information
  • Service Type
  • Initial Evaluation Date
  • Diagnosis Code
  • If this request for post or pre-operative therapy visits
  • Requested # of Visits
You will find this Authorization template in the below link:


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    Post Operative Care in New York NY

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    Post Operative Care in New Jersey

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