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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.17 Inpatient Rehabilitation Facility (Freestanding) (CCP) : 2.17.3 Prior Authorization and Documentation Requirements

2.17.3
All inpatient rehabilitation services provided to clients who are birth through 20 years of age in a freestanding inpatient rehabilitation facility require prior authorization.
Prior authorization will be considered when the client has met all of the following criteria:
The client has an acute problem or an acute exacerbation of a chronic problem resulting in a significant decrease in functional ability that will benefit from inpatient rehabilitation services.
The physician and the provider must maintain all documentation in the client’s medical record.
Inpatient rehabilitation may be prior authorized for up to two months when the attending physician submits documentation of medical necessity. The treatment plan must indicate that the client is expected to improve within a 60-day period and be restored to a more functional lifestyle for an acute condition or the previous level of function for an acute exacerbation of a chronic condition.
Requests for subsequent services for increments up to 60 days may be prior authorized based on medical necessity. Requests for prior authorization of subsequent services must be received before the end-date of the preceding prior authorization.
A prior authorization request for an additional 60 days of therapy will be considered with documentation supporting medical necessity.
Supporting documentation for an initial request must include the following:
The request for inpatient rehabilitation and the treatment plan must be signed and dated by the physician. The physician’s signature is valid for no more than 60 days prior to the requested start of care date.
An updated written comprehensive treatment plan established by the attending physician or by the therapist to be followed during the inpatient rehabilitation admission that:
Is under the leadership of a physician and includes a description of the specific therapy being prescribed, diagnosis, treatment goals related to the client’s individual needs, and duration and frequency of therapy.
After receiving the documentation establishing the medical necessity and plan of medical care by the treating physician, prior authorization is considered by CCP for the initial service and an extension of service as applicable. A request for prior authorization must include documentation from the provider to support the medical necessity of the service.

Texas Medicaid & Healthcare Partnership
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