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December 2016 Texas Medicaid Provider Procedures Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook : 5 Children’s Therapy Services Clients birth through 20 years of age : 5.2 Authorization Requirements for PT, OT, and ST Services : 5.2.1 Initial Evaluation and Considerations for Prior Authorization for Treatment

5.2.1
Initial evaluations do not require prior authorization (procedure codes 97001, 97003, 92521, 92522, 92523, 92524, and 92610); however, documentation kept in the client’s record must include a signed and dated prescribing provider’s order for the evaluation, support a medical need for the therapy evaluation, and be available when requested.
A therapy evaluation is considered current when it is performed within 60 days before the prior authorization request is received.
To complete the prior authorization process by paper, the provider must complete and submit the prior authorization requirements documentation through fax or mail, and must maintain 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 complete and submit the prior authorization requirements documentation through any approved electronic method, and must maintain 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 prescribing provider must provide correct and complete information, including documentation of medical necessity for the service(s) requested. The prescribing provider 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.
Therapy services, regardless of place or provider, occurring after the initial evaluation, require prior authorization. PT, OT, or ST services may be prior authorized to be provided in the following locations: home of the client, home of the caregiver or guardian, client’s daycare facility or the client’s school.

Texas Medicaid & Healthcare Partnership
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