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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.10 Therapy Services (CCP) : 2.10.1 Occupational Therapy (OT) : Prior Authorization and Documentation Requirements
Prior authorization is required for occupational therapy except for therapy provided in the inpatient setting, evaluations or reevaluations, 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 2.5, “Early Childhood Intervention (ECI) Services” in this handbook for more information about ECI.
The following documentation must be submitted to TMHP prior to the start of care for the current episode of therapy for consideration for prior authorization:
A “Request for Initial Outpatient Therapy (Form TP-1)” or “Request for Extension of Outpatient Therapy (2 Pages) (Form TP-2)” must be submitted to TMHP prior to the start of care for the current episode of therapy.
Specific treatment goals related to the client's individual needs. Therapy goals may include improving function, maintenance of function, or slowing of the deterioration of function.
The number of sessions per week must be supported by documentation supporting the medical necessity for the frequency requested.
When requesting prior authorization for group occupational therapy, the provider must submit documentation supporting the group process as being medically necessary and beneficial to the client. When group therapy is authorized, weekly therapy limits will not be exceeded.
An advanced practice registered nurse (APRN) or a physician assistant may sign all documentation related to the provision therapy services on behalf of the client's physician when the physician delegates this authority to the APRN or physician assistant.
A request for OT services may be prior authorized for no longer than 180 days duration. A new request must be submitted if therapy is required for a longer duration.
The GO modifier is required on all prior authorization requests for occupational therapy.
If a provider discontinues therapy with a client and a new provider begins therapy during an existing authorization period, submission of a new plan of care and documentation of the last therapy visit with the previous provider is required along with a letter from the client, or responsible adult, stating the date therapy ended with the previous provider.

Texas Medicaid & Healthcare Partnership
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