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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 : 5.2.5 Requests for Recertification - Chronic Therapy Services

5.2.5
5.2.5.1
A reevaluation is a comprehensive evaluation and must take place every 180 days and contains all the elements of an initial evaluation, including affirmation that the client’s THSteps checkup is current or that a developmental screening was performed by the prescribing provider within the last 60 days. It may be used to make a determination whether or not skilled therapy is medically necessary, or when determining the effectiveness of the current plan, or when the current plan requires significant modification and revision of the interventions and goals due to changes in the client’s medical status or lack of progress with the current treatment. A reevaluation requires authorization and must be submitted with the recertification request (procedure codes 97002, 97004, and S9152).
Routine reassessments that occur during each treatment session or visit or for a progress report required for an extension of services or discharge summary are not considered a comprehensive reevaluation.
Tests used must be norm-referenced, standardized, and specific to the therapy provided.
Refer to:
Subsection 5.3, “Developmental Delay Criteria” in this handbook for information about documentation about developmental delay criteria.
A recertification request may be considered when services will be medically needed after the previously approved authorization period ends.
A complete request must be received no earlier than 30 days before the current authorization period expires.
Requests for recertification services received after the current authorization expires will be denied for dates of service that occurred before the date the request is received.
A reevaluation may occur as early as 60 days prior to the end of the current authorization period.
A therapy reevaluation is considered current when it is performed within 60 days before the current authorization period expires.
The reevaluation must occur within 30 days of the signed and dated order from the referring provider.
Prior authorization for recertification requests may be considered for increments up to 180 days for each request with documentation supporting the medical necessity including all of the following:
Texas Medicaid Physical, Occupational, or Speech Therapy (PT, OT, ST) Prior Authorization Form or electronic equivalent signed and dated by the therapist and by the prescribing provider. When the request form is unsigned by the prescribing provider, it must be accompanied by a written order or prescription or a verbal order for the prescribed therapy services.
Documentation that the THSteps checkup is current or that a developmental screening was performed by the prescribing provider within the last 60 days
Note:
Additional documentation is not necessary if the prescribing provider signs the Texas Medicaid Physical, Occupational, or Speech Therapy (PT, OT, ST) Prior Authorization Form.
Refer to:
Subsection 5.3, “Developmental Delay Criteria” in this handbook for information about documentation about developmental delay criteria.
Updated or new functional and measurable short and long-term treatment goals with new time frames, as applicable. Previous authorization period’s goals and progress must be included.
Documentation of consults with other professionals and services or referrals made and coordination of service when applicable (e.g., for school aged clients, documentation of the coordination of care and referrals made for school therapies)

Texas Medicaid & Healthcare Partnership
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