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December 2016 Texas Medicaid Provider Procedures Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook : 6 Adult Services : 6.2 Authorization Requirements for Outpatient and Home Health —PT, OT, and ST Services : 6.2.1 Initial Evaluation and Considerations for Prior Authorization for Treatment

6.2.1
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.
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 physician must provide correct and complete information, including documentation of medical necessity for the service(s) requested. The physician 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. Prior authorization requests may not exceed a 60 day period.
Prior authorization (PA) requests must be received no later than five business days from the date therapy treatments following the evaluation 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 is received.

Texas Medicaid & Healthcare Partnership
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