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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 : 5.2.1.1 Initial Evaluation for Acute and Chronic Therapy Services

5.2.1.1
For acute therapy services, i.e. acute services billed with an AT modifier, prior authorization requests may not exceed a 60 day period per each request. After two 60 day authorized periods, any continued requests for therapy services must be considered under the chronic sections of this handbook.
For chronic therapy services, prior authorization may be granted for up to 180 days with documentation of medical necessity and additional prior authorizations.
Initial prior authorization (PA) requests must be received no later than five business days from the date therapy treatments are initiated. Requests received after the five-business-day period will be denied for dates of service that occurred before the date that the PA request was received.
All of the following documentation is required when submitting an initial request for therapy services initiated after the completion of the evaluation for acute or chronic services:
A completed Texas Medicaid Physical, Occupational, or Speech Therapy (PT, OT, ST) Prior Authorization Form signed and dated by both the therapist and by the prescribing provider is required. When the request form is unsigned by the prescribing provider, it must be accompanied by a signed and dated written order or prescription or a documented verbal order delineating the prescribed therapy services.
The prescribing provider must certify that the Texas Health Steps (THSteps) checkup is current or that a developmental screening has been performed within the last 60 days. Signature of prescribing provider on PA form will attest that this service has been provided. If prescribing provider provides verbal order or written order separate from PA form, staff member who conveys the verbal or written order must communicate that prescribing provider attests that THSteps checkup is current or that a developmental screening has been performed within the last 60 days.
For acute services: Documentation from the prescribing provider that a visit for the acute or acute exacerbation of the medical condition requiring therapy has occurred within the last 90 days.
Refer to:
Subsection 5.3, “Developmental Delay Criteria” in this handbook for information about chronic services.

Texas Medicaid & Healthcare Partnership
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