1 PROTOCOLS FOR OCCUPATIONAL THERAPY PROVIDERS Type of Services Provided Services provided by Occupational Therapy providers are covered for Santa Barbara Health Initiative (SBHI), San Luis Obispo Health Initiative (SLOHI), Healthy Families Program (HFP), Healthy Kids (HK), Prenatal PLUS 2 (PP2), and In-home Supportive Services (IHSS) members. These services include treatment prescribed by a physician to restore or improve a person s ability to undertake activities of daily living when those skills are impaired by developmental or psycho-social disabilities, physical illness or advanced age. Members may access Occupational Therapy services including: occupational therapy evaluation, treatment planning, treatment, instruction, and consultations. Covered Occupational Therapy (OT) Benefits for IHSS The following procedures are Covered Benefits: OT services are a covered benefit only when services are provided pursuant to a written treatment plan or written prescription of a CenCal Health physician or podiatrist, which is within the scope of their medical practice. See below for additional information on information needed on the prescription or written treatment plan OT services are only covered when care is rendered in the Provider s office or in an outpatient department of a hospital facility OT services must be performed by licensed and registered therapists OT services are also covered when the member is an inpatient at an acute care hospital, or at a rehabilitation hospital Covered OT Benefits for SBHI, SLOHI, HFP, HK and PP2 The following procedures are Covered Benefits: OT services are a covered benefit only when services are provided pursuant to a written treatment plan or written prescription of a CenCal Health physician or podiatrist, which is within the scope of their medical practice. See the Provider Manual for additional information on what is required in the prescription or written treatment plan OT services are only covered when care is rendered in the Provider s office, in an outpatient department of a hospital facility, or as authorized to be provided in the Member s home OT services must be performed by licensed and registered therapists OT services are also covered when the Member is an inpatient at an acute care hospital, in a skilled nursing facility, or at a rehabilitation hospital Limitations for IHSS The maximum number of aggregate Occupational Therapy, physical therapy, and speech therapy Visits, in an outpatient setting, is limited to 36 Visits per calendar year. Additional visits may be authorized as Medically Necessary with evidence of continued significant improvement, as part of an approved treatment plan.
2 Non-Covered Charges Non-authorized services are not covered IHSS - visits beyond the limit of 36, unless additional visits are Medically Necessary and are authorized as set forth below. Occupational Therapy providers will be responsible for: First determining the eligibility of members to receive services For meeting the elements of Occupational Therapy services and for documenting services as indicated below For submitting claim forms to CenCal Health. Eligibility Occupational Therapy providers must confirm that the member presenting in his/her office is eligible for services under CenCal Health and is assigned to the referring PCP for the month in which he/she is to render services. This can be accomplished by verifying eligibility through one of CenCal Health s systems. Information regarding eligibility is in the Member Services Section of this Provider Manual. In the event the member is not eligible under the program(s) administered by CenCal Health, payment for any services provided to the member will not be the responsibility of CenCal Health. Treatment Plan (required for all members when requesting authorization) The following must be present on the written treatment or prescription plan: Signature of the prescribing practitioner Name, address and telephone number of the prescribing practitioner Date of treatment or prescription plan Medical condition necessitating the service(s) (diagnosis) Supplemental summary of the medical condition or functional limitations Specific services (for example, evaluation, treatments, modalities) prescribed Frequency of services Duration of medical necessity for services specific dates and length of treatment should be identified if possible. Duration of therapy should be set by prescriber Anticipated medical outcome as a result of the therapy (therapeutic goals) Date of progress review (when applicable) Age of member Mental status and ability to comprehend Related medical conditions Any delay in achievement of developmental milestones or impairment of normal achievement The treatments or prescriptions must be realistically related to activities of daily living such as nutrition, elimination, dressing, and locomotion, in light of the patient s functional limitations. The specific goals of training or devices prescribed must also be indicated.
3 Documentation of Services The Occupational Therapy provider shall document services by completing a claim form and submitting the form to CenCal Health. Occupational Therapy providers shall also provide documentation to the member s PCP. Authorizations Occupational Therapy providers are required to obtain a prescription from the member s PCP, or any qualified physician, for Occupational Therapy services provided to all members. Referral Authorization Forms (RAFs) are not required for services under any program. Additionally, all occupational therapy services require a Treatment Authorization Request (TAR) or an Authorization Request (AR) to be approved by CenCal Health. Please refer to the TAR/AR Sections of this Provider Manual for more information. Specific Authorization of Occupational Therapy Services For Occupational Therapy services which require prior authorization by CenCal Health, approval is limited to services which: Are necessary to prevent or substantially reduce an anticipated hospital stay Continue a plan of treatment initiated in the hospital Are recognized as a logical component of post hospital care Billing for Covered Services Occupational Therapy providers bill CenCal Health for the Occupational Therapy services he or she has provided to the eligible member. In the event the member has other coverage, or third-party liability is involved, the Occupational Therapy provider shall follow the terms and conditions of his/her Agreement with CenCal Health, or as indicated in Other Health Coverage in the Claims Section of this Provider Manual. Occupation Therapy Services: Occupational Therapy providers shall bill using Provider s valid billing number The ICD-9-CM diagnosis code(s) of the member s condition must be on the claim If member s condition is related to employment, then CMS-1500 box 10a must be checked YES ; For IHSS only- If member s condition is related to an auto accident, then CMS-1500 box 10b must be checked YES Copayments Copayments for Occupational Therapy services for the following members should be collected at the time the service is rendered: IHSS members: HFP/HK members: PP2 members: $15 Copayment when provided in a medical office, home or outpatient setting and when ordered by the member s PCP $5 Copayment when provided in a medical office, home or outpatient setting no Copayment Procedure Codes SBHI & SLOHI- Allied Health Providers who have rendered Covered Services to eligible SBHI and SLOHI Members shall submit Claim forms within one (1) year of the date of service, in accordance with the provisions of Section 4.6 of the Agreement. However, Claims submitted
4 after six (6) months will be reduced to 75% of the allowable, and those submitted after nine (9) months from the date of service will be reduced to 50% of the allowable. Occupational Therapy Provider shall bill for services using procedure codes referenced in Title 22, CCR, S , Occupational Therapy, or as indicated in the EDS Medi-Cal Provider Manual. HF/HK/PP2 and IHSS- Allied Health Provider should submit Claims within one hundred and eighty (180) days of the date of service. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) Billing Codes. Allied Health Provider shall bill for services for HF/HK/PP2 and IHSS Members within the acceptable range of CPT and/or HCPCS billing codes as established in the most recently published American Medical Association s (AMA) CPT guide and/or the HCPCS guide as published by the federal Department of Health and Human Services (HHS). IHSS Reimbursement for Occupational Therapy Services Occupational Therapy provider shall be reimbursed for Covered Services rendered to members as follows: The lessor of (a) allowable billed charges, less applicable member per visit Copayment or (b) Contract Rate, less applicable member per visit Copayment; subject to submission of complete claims. The Contract Rate for Occupational Therapy CPT codes shall be 100% of the applicable Medicare Fee Schedule for CPT codes with an established Medicare rate. For CPT codes without an established Medicare rate, the Contract Rate shall be 100% of CenCal Health s Fee Schedule. In the event member Copayment exceeds allowable billed charges or Contract Rate, Provider will be reimbursed $0.00. SBHI & SLOHI Reimbursement for Occupational Therapy Services Occupational Therapy Provider and its Subcontractors agree and understand that they will accept the State Medi-Cal rate in effect at the time or service, or CenCal Health s rate in effect at the time of service, whichever is higher. Occupational Therapy Provider may request rate information for specified reimbursement codes for its specialty by contacting the Provider Services Department or a Claims Representative, or by accessing the Procedure Pricer on CenCal Health s website for rates and on the Medi-Cal website for Medi-Cal rates. CMS Correct Coding Initiative (CCI) Edits Occupational Therapists may submit claims for procedures in which CMS Correct Coding Initiative (CCI) edits will apply. These edits and the listed corresponding CPT groupings are considered mutually exclusive procedures which cannot reasonably be performed by the same Provider, on the same member on the same date of service. A listing of applicable codes is as follows:
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