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The Texas Health and Human Services Commission (HHSC) must update interim claiming and cost reporting requirements for School Health and Related Services (SHARS) Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and Audiology services in accordance with Title 42 Code of Federal Regulations (CFR) §455.440 National Provider Identifier, CFR §455.410 Enrollment and Screening of Providers, and CFR §440.110 Physical Therapy, Occupational Therapy, and Services for Individuals with Speech, Hearing, and Language Disorders.
These updates are necessary to mitigate potential interim claiming and cost reporting denials due to a missing referring or prescribing provider National Provider Identifier (NPI). All referring and prescribing providers, regardless of direct employment with school districts, must obtain an NPI and must be enrolled in Medicaid as individual practitioners.
The following updates for SHARS PT, OT, ST, and Audiology services will be effective October 1, 2021:
Definitions for Prescription and Referral
Prescription and referral are defined as follows:
- A prescription is a written order for services (such as PT or OT) from the ordering physician or other eligible prescribing provider.
- A referral is a written document requesting evaluation for services (such as ST or Audiology) from the referring physician or other eligible referring provider.
Physical and Occupational Therapy
- A prescription is required for all PT and OT services to receive SHARS reimbursement. The prescription must be updated a minimum of one time every three calendar years.
- A physician or another eligible prescribing provider must prescribe PT and OT services.
- Prescriptions for PT and OT services must be signed and dated within three calendar years before the initiation of services.
- PT and OT services may be reimbursed up to, but no more than, the amount designated on the prescription.
- The name and NPI of the licensed physician or other eligible prescribing provider must be listed on the claim and kept in the medical record for PT and OT services to be reimbursed through SHARS.
Speech Therapy and Audiology
- A referral is required for all ST and Audiology services to receive SHARS reimbursement. The referral must be updated a minimum of one time every three calendar years.
- A physician or another eligible referring provider must refer for ST and Audiology services.
- Referrals for ST or audiology services must be signed and dated within three calendar years before the initiation of services.
- The name and NPI of the referring licensed physician or another eligible referring provider must be listed on the claim and kept in the medical record for reimbursement of ST or Audiology services through SHARS.
- STs and audiologists whose evaluations serve as the referral must be enrolled in Medicaid as individual practitioners and must use their individual NPIs when submitting claims.
- This change means SHARS providers must provide a prescribing or referring NPI provider number for PT, OT, ST and Audiology services only.
- No other services rendered by SHARS providers require a prescribing or referring NPI.
For more information, call the TMHP Contact Center at 800-925-9126.