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April 2014 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.11 Therapy Services (CCP) : 2.11.1 Occupational Therapy (OT) : 2.11.1.3 * Prior Authorization and Documentation Requirements

2.11.1.3
Prior authorization is required for OT except for therapy provided in the acute care inpatient setting, evaluations or re-evaluations, services provided through the SHARS or Early Childhood Intervention (ECI) programs.
Refer to:
Section 3, “School Health and Related Services (SHARS)” in this handbook for more information about SHARS.
Subsection 2.6, “Early Childhood Intervention (ECI) Services” in this handbook for more information about ECI.
Prior authorization for individual therapy services will be considered when all of the following criteria are met:
An initial prior authorization may be granted for a period not to exceed 180 days per event for acute care services. Subsequent prior authorization requests may be requested for up to 180 days when submitted with documentation of a chronic condition.
Coverage periods do not necessarily coincide with calendar weeks or months, but instead cover a number of services to be scheduled between a start date and end date that is assigned during the prior authorization period. Prior authorization requests for OT services may be requested with either a weekly frequency or monthly frequency, but not both. A week includes the day of the week on which the prior authorization period begins and continues for total of seven days. The number of therapy services authorized for a week must be provided in that prior authorization week. A month includes the day of the month on which the prior authorization period begins and continues for 30 days. The number of therapy services authorized for a month must be provided in that prior authorization month. Claims for services that exceed those authorized for the prior authorization week or month are subject to recoupment.
All documentation that is related to the therapy services that are prior authorized and provided, including medical necessity and the comprehensive treatment plan, must be maintained in the client's medical record and made available upon request. For each therapy discipline that is provided, the documentation that is maintained in the client's medical record must identify the therapy provider's name and include all of the following:
To complete the prior authorization process by paper, the provider must submit the required documentation through fax or mail and must retain a copy of the prior authorization request and all submitted documentation in the client's medical record at the therapy provider's place of business.
To complete the prior authorization process electronically, the provider must submit the required documentation through any approved electronic method and must retain a copy of the prior authorization request and all submitted documentation in the client's medical record at the therapy provider's place of business.
To avoid unnecessary denials, the physician must submit correct and complete information including documentation of medical necessity for the service requested. The physician must maintain documentation of medical necessity in the client's medical record. The requesting therapy provider may be asked for additional information to clarify or complete a request for therapy.
2.11.1.3.1 * Initial Prior Authorization Requests
Therapy services may be initiated upon the receipt of the physician's order. Therapy services initiated before the date of the physician order will not be approved.
The initial request for prior authorization must be received no later than five business days from the date therapy treatments are initiated. Requests that are received after the five business-day period will be denied for dates of service that occurred before the date that the request was received.
The following supporting documentation must be submitted for an initial prior authorization request:
A completed Request for CCP Outpatient Therapy prior authorization form. The request form must be signed and dated by the ordering physician.
If the prior authorization form is not signed and dated by the physician, the form must be accompanied by a written order or prescription that is signed and dated by the physician, or a documented verbal order from the physician that includes the date that the verbal order was received.
Note:
A verbal order is considered current when the date received is on or no more than 60 days before the start of therapy. A written order or prescription is considered current when it is signed and dated on or no more than 60 days before the start of therapy.
A request received without a physician's signature, documented verbal order, or written prescription will not be processed and will be returned to the provider.
Note:
A therapy evaluation is current when it is performed within 60 days before the initiation of therapy services.
A client-specific comprehensive treatment plan that is established by the ordering physician or therapist to be followed during treatment and includes all of the following:
A CNM, CNS, NP, or PA may sign all documentation related to the provision of therapy services on behalf of the client's physician when the physician delegates this authority.
The GO modifier is required on all prior authorization requests for OT.
2.11.1.3.2 * Subsequent Prior Authorization Requests
A prior authorization request for subsequent services must be received no more than 30 days before the current authorization expires. Prior authorization requests for subsequent services that are received after the current authorization expires will be denied for dates of service that occurred before the date that the submitted request was received.
Prior authorization requests for subsequent services may be considered with documentation that supports medical necessity and includes all of the following:
A completed Request for CCP Outpatient Therapy prior authorization form that has been signed and dated by the ordering physician
If the prior authorization form is not signed and dated by the physician, the form must be accompanied by a written order or prescription that is signed and dated by the physician, or a documented verbal order from the physician that includes the date the verbal order was received.
Note:
A verbal order is considered current when the date received is on or no more than 60 days before the start of therapy. A written order or prescription is considered current when it is signed and dated on or no more than 60 days before the start of therapy.
A request received without a physician's signature, documented verbal order, or written prescription will not be processed and will be returned to the provider.
A therapy evaluation or re-evaluation for subsequent services is current when performed within 30 days before the prior authorization request is received. For example:
If an authorization period ends on July 31, 2014, TMHP must receive the prior authorization request for subsequent services between July 1, 2014, and July 31, 2014.
The therapy evaluation or re-evaluation for subsequent services can be performed up to 30 days before the date that TMHP receives the prior authorization request.
If TMHP receives the prior authorization request for subsequent services on July 1, 2014, the evaluation or re-evaluation can be performed June 1, 2014, through July 1, 2014.
If TMHP receives the prior authorization request for subsequent services on July 31, 2014, the evaluation or re-evaluation can be performed July 1, 2014, through July 31, 2014.
An updated, client-specific comprehensive treatment plan that was established by the ordering physician or therapist to be followed during treatment must include all of the following:
2.11.1.3.3 * Revisions to Existing Prior Authorization Requests
A prior authorization request for revisions to services may be considered up to the end of the current approved prior authorization.
Requests for revisions to an existing authorization must be received no later than five business days from the date that the revised therapy treatments are initiated. Requests that are received after the five business-day period will be denied for dates of service that occurred before the date that the request was received.
If a provider or client discontinues therapy during an existing prior authorized period and the client requests services through a new provider, the new provider must submit all of the following:
A change-of-provider letter that has been signed and dated by the client or responsible adult and that documents the date that the client ended therapy (effective date of change) with the previous provider, the names of the previous and new providers, and an explanation of why providers were changed.
A change of provider during an existing authorization period will not extend the original authorization period approved to the previous provider. Regardless of the number of provider changes, clients may not receive therapy services beyond the limitations outlined in this section.
2.11.1.3.4 Frequency Levels
OT services may be provided at one of the following levels commensurate with the client's medical condition, developmental needs, life stage, and therapy needs that are identified in the documentation submitted:
The client requires a high frequency of intervention for a limited duration (60 days or fewer) to achieve an identified new skill or recover function lost due to surgery, illness, or trauma.
The licensed therapist needs to adjust the client's therapy plan and home program weekly or more often than weekly based on the client's progress and medical needs.
The client is making progress toward the client's goals, but the progress has slowed, or the client may be at risk of deterioration due to the client's development or medical condition.
Every other week therapy is supported for clients whose medical condition is stable, they are making progress, and it is anticipated the client will not regress with every other week therapy. Because the therapy plan changes very slowly, the home program can be managed by the client and the responsible adult and does not require frequent changes by the licensed therapist.
Maintenance Level/Prevent Deterioration: every other week to monthly or less often visits/sessions may be considered when the client meets one of the following criteria:
Factors are identified that inhibit the client's ability to achieve established goals (e.g., the client cannot participate in therapy sessions due to behavior issues or issues with anxiety)
Documentation shows the client and the responsible adult have a continuing need for education, a periodic adjustment of the home program, or regular modification of equipment to meet the client's needs
As a client's condition improves and goals are met, it is anticipated the therapist will decrease to a lesser frequency level.

Texas Medicaid & Healthcare Partnership
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