Cenpatico STRS POLICIES & PROCEDURES. Retired Date: Cross Reference:

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1 Page 1 of 25 Procedure Name: Physical, Occupational and, 06/20/12 Table of Contents SCOPE:... 2 PURPOSE:... 2 Description...2 Policy/Criteria:...3 Outpatient or Home Health Therapy Authorization Guidelines...5 A. Initial Authorization...5 B. Continued Authorization...7 C. Discontinuation of Therapy...9 D. Children with Developmental Delays...10 Comprehensive Day Rehab (CDR) Authorization Guidelines...12 A. Limitations...12 B. Admission Criteria and Initial Authorization...12 C. Continued Authorization...14 D. Discontinuation of CDR...15 REVISION LOG...18 Page 1 of 25

2 Page 2 of 25 SCOPE: Clinical Department IMPORTANT REMINDER This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted standards of medical practice, peer-reviewed medical literature, government agency/program approval status, and other indicia of medical necessity. The purpose of this Clinical Policy is to provide a guide to medical necessity. Benefit determinations should be based in all cases on the applicable contract provisions governing plan benefits ( Benefit Plan Contract ) and applicable state and federal requirements, as well as applicable plan-level administrative policies and procedures. To the extent there are any conflicts between this Clinical Policy and the Benefit Plan Contract provisions, the Benefit Plan Contract provisions will control. Clinical policies are intended to be reflective of current scientific research and clinical thinking. This Clinical Policy is not intended to dictate to providers how to practice medicine, nor does it constitute a contract or guarantee regarding results. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. PURPOSE: To provide guidelines for the authorization of outpatient Speech Therapy, Occupational Therapy, and/or Physical Therapy evaluation and treatment Services. Description Physical and Occupational Therapy are defined as therapeutic interventions and services that are designed to improve, develop, correct or ameliorate, rehabilitate or prevent the worsening of physical functions and functions that affect activities of daily living (ADLs) that have been lost, impaired or reduced as a result of an acute or chronic medical condition, congenital anomaly or injury. Various types of interventions and techniques are used to focus on the treatment of dysfunctions involving neuromuscular, musculoskeletal, or integumentary systems to optimize functioning levels and improve quality of life. Speech therapy is defined as services that are necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability. Speech therapy is designed to correct or ameliorate, restore or Page 2 of 25

3 Page 3 of 25 rehabilitate speech/language communication and swallowing disorders that have been lost or damaged as a result of chronic medical conditions, congenital anomalies or injuries. Policy/Criteria: 1. Outpatient Speech Therapy, Occupational Therapy, and/or Physical Therapy evaluation and treatment services are considered medically necessary when all the following criteria are met (In South Carolina, refer to Attachment A when issuing an authorization for a hospitalbased outpatient setting): a. The member exhibits signs and symptoms of physical deterioration or impairment in one or more of the following areas: Sensory/Motor Ability Functional Status as evidenced by an inability to perform basic activities of daily living (ADLs): Cognitive/Psychological Ability Cardiopulmonary Status Speech/Language/Swallowing Ability b. The treatment is ordered by an examining Physician and a formal evaluation is conducted by a Licensed/Registered Speech, Occupational or Physical Therapist; The evaluation must include all of the following: History of illness or disability Relevant review of systems Pertinent physical assessment Current and previous level of functioning Tests or measurements of physical function Potential for improvement in the patient s physical function Recommendations for treatment and patient and/or caregiver education Page 3 of 25

4 Page 4 of 25 c. The treatment requires the judgment, knowledge, and skills of a Licensed/Registered Speech, Occupational or Physical Therapist or Therapy Assistant (SLPA, COTA or PTA). d. The treatment cannot be reasonably learned and implemented by Non-Professional or Lay Caregivers. Repetitive therapy drills which do not require a Licensed/Certified Professional s feedback are not covered services; e. The ordered treatment meets accepted standards of discipline-specific clinical practice, and is targeted and effective in the treatment of the Member s diagnosed impairment or condition; f. The treatment does not duplicate services provided by other types of Therapy, or services provided in multiple settings (See section regarding School Based Therapy); g. The treatment conforms to a Plan of Care specific to the Member s diagnosed impairment or condition: The written plan of care must include all of the following: Diagnosis with date of onset or exacerbation Short and long term functional treatment goals that are specific and measurable Treatment techniques and interventions to be used amount, frequency, and duration required to achieve measurable goals Education of the member and primary caregiver, if applicable Summary of results achieved during previous periods of therapy, if applicable h. There is an expectation that the treatment will produce clinically significant and measurable improvement in the Member s level of functioning within a reasonable, and medically predictable period of time; i. The treatment is part of a medically necessary program to prevent significant functional regression and meets one of the following criteria (Refer to Attachment B, regarding Texas): When a member (child or under 21) achieves a relative clinical and functional plateau, the provider adjusts the Plan of Care accordingly, and provides monthly (or as appropriate) reassessments to update and modify, as necessary, the Home Care Program. If the member's functional level is Page 4 of 25

5 Page 5 of 25 discovered to be in jeopardy or declining, the Plan of Care can be adjusted accordingly by the therapy provider. EPSDT Members: Members who are receiving EPSDT services may continue to receive demonstrated medically necessary therapies where loss or regression of present level of function is likely within a reasonable and medically predictable period of time. j. Where appropriate, InterQual Criteria will be used as a guideline in the medical necessity decision making process - (Please refer to the Outpatient Rehabilitation and Chiropractic InterQual Subsets Guidelines). 2. Medically Necessary Services refers to services or treatments which are ordered by an examining Physician and which (pursuant to the EPSDT Program) diagnose or correct or significantly ameliorate defects, physical and mental illnesses, and health conditions. Correct or ameliorate means to optimize a Member s health condition, to compensate for a health problem, to prevent a serious medical deterioration, or to prevent the development of additional health problems. 3. Not all treatment modalities are covered benefits. Coverage of specific modalities depends upon their proven efficacy, safety, and medical appropriateness as established by accepted and discipline-specific Clinical Practice Guidelines. 4. Treatment of the Member in the home may be medically necessary if the treatment can be safely and adequately performed in the Member s home environment, and the Member s diagnosed impairment or condition makes transportation to an Outpatient Rehab Facility impractical or medically inappropriate. Outpatient or Home Health Therapy Authorization Guidelines A. Initial Authorization 1. Initial Evaluations: Please refer to your individual state benefits for guidance (Refer to state attachments). 2. Initial authorization for Treatment, following evaluation: Members with clearly diagnosed impairments or conditions may receive an initial Authorization for a specified number of Visits. Page 5 of 25

6 Page 6 of 25 The Plan of Care signed by the therapist must document the following (Refer to state attachments): A brief history of treatment provided to the Member by the current or most recent Provider; A description of the Member s current level of functioning or impairment, and identification of any known primary or secondary health conditions which could impede the Member s ability to benefit from treatment. a. Providers must include the Member s most recent Standardized Evaluation scores, with documentation of age equivalency, percent of functional delay, or Standard Deviation (SD) score when appropriate for the Members diagnosis/disability. b. Providers should also include any meaningful clinical observations, summary of a Member s response to the evaluation process, and a brief prognosis statement. A clear diagnosis specific to the reason for receiving therapy; Planned treatment modalities, their anticipated frequency and duration; Short and long-term Treatment Goals which are functional, specific to the Member s diagnosed condition or impairment, and measurable relative to the Member s anticipated treatment progress. Physician signature must be on the plan of care or on a prescription noting the service type (See attachment A for state specific information). Utilization Review Personnel must document the following information in the Notes Section of the Authorization: Diagnosis and type of service being rendered Number of visits authorized Page 6 of 25

7 Page 7 of 25 If the clinical information submitted by the requesting Provider is insufficient to make a determination, the Utilization Review Personnel shall contact the Provider and request that the required information be sent. If there is a question as to whether the submitted information warrants additional therapeutic intervention, the Utilization Review Personnel shall refer the Request to the Medical Director or physician designee for final review and determination. The Medical Director or physician designee is the only Reviewer permitted to make an Adverse Determination due to failure to meet Medical Necessity Criteria. 3. Treatment may be approved according to a Member s diagnosed level of severity as long as a clearly documented prognosis is included which establishes the Member s likelihood to develop or recover the anticipated skills or functions (identified as the clinical rationale for initiating or continuing treatment) within a reasonable and medically predictable period of time. Where appropriate, InterQual Criteria will be used as a guideline in the medical necessity decision making process. The frequency of treatment may be approved in accordance with the following: Mild Delays = Up to 1x per Week Moderate Delays = Up to 2x per Week Severe Delays = Up to 3x per Week 4. If Services are approved, a communication will be sent to the Provider indicating Approval. Up to six (6) months of treatment may be requested and authorized, when determined medically necessary and the medical prognosis clinically supports the need for up to six (6) months of treatment. 5. If Services are denied, the Utilization Review Personnel shall follow the established Denial Process and Guidelines. B. Continued Authorization 1. Treatment progress must be clearly documented in an updated Plan of Care/current progress summary signed by the therapist, as submitted by the requesting Provider at the end of each authorization period and/or when additional Visits are being requested. Page 7 of 25

8 Page 8 of 25 a. Documentation must include the following: The Member s updated Standardized Evaluation scores, with documentation of age equivalency, percent of functional delay, or Standard Deviation (SD) score, if applicable Objective measures of the Member s functional progress relative to each Treatment Goal, and a comparison to the previous Progress Report Summary of Member s response to Therapy, with documentation of any issues which have limited progress Documentation of Member s participation in treatment as well as Member/Caregiver participation or adherence with a Home Exercise Program (HEP) Brief prognosis statement with clearly established discharge criteria An explanation of any significant changes to the Member s Plan of Care, and the clinical rationale for revising the Plan Prescribed treatment modalities, their anticipated frequency and duration Physician signature must be on the plan of care or on a prescription noting the service type (See attachment A for state specific information). 2. Treatment may be approved according to a Member s diagnosed level of severity as long as a clearly documented prognosis is included which establishes the Member s likelihood to develop or recover the anticipated skills or functions (identified as the clinical rationale for initiating or continuing treatment) within a reasonable and medically predictable period of time. Where appropriate, InterQual Criteria will be used as a guideline in the medical necessity decision making process. The frequency of treatment may be approved in accordance with the following: Mild Delays = Up to 1x per Week Page 8 of 25

9 Page 9 of 25 Moderate Delays = Up to 2x per Week Severe Delays = Up to 3x per Week 3. If Services are approved, a communication will be sent to the Provider indicating Approval. Up to six (6) months of treatment may be requested and authorized, when determined medically necessary and the medical prognosis clinically supports the need for up to six (6) months of treatment. 4. Updated clinical information must be received from the Provider prior to authorization of additional Visits, and should be attached in the Notes Section of the Authorization. a. The following information should also be documented in the Notes Section of the Authorization: additional number of Visits and type of Therapy authorized (i.e., Approved an additional 9 Visits of Speech Therapy). C. Discontinuation of Therapy 1. Reasons for discontinuing treatment may include, but are not limited to, the following: Member has achieved Treatment Goals as evidenced by one or more of the following: 1. Member no longer demonstrates functional impairment or has achieved goals set forth in the Plan of Care 2. Member has returned to baseline function 3. Member will continue therapy with a home therapy exercise program 4. Member s deficits no longer require a skilled therapy intervention 5. Member has adapted to impairment with assistive equipment or devices 6. Member is able to perform ADLs with minimal to no assistance from caregiver Page 9 of 25

10 Page 10 of 25 Member has reached a functional plateau in progress, or will no longer benefit from additional Therapy Member is unable to participate in the Plan of Care due to medical, psychological, or social complications Non-compliance with a Home Exercise Program (HEP) and/or lack of participation in scheduled Therapy appointments 2. If Therapy no longer appears to be clinically appropriate and/or beneficial to the Member for any reason, including those identified above, a recommendation for discontinuation should be referred to the Medical Director or physician designee for final review and determination. D. Children with Developmental Delays 1. Some states have state-funded Early Intervention Programs wherein children between the ages of (0-3), who are identified with Developmental Delays, may be eligible for an Individual Family Service Plan (IFSP) in which treatment and/or family support services are provided for free or at a minimal cost. These do not require Prior Authorization. 2. When a request is being made for authorization of an Early Intervention Program, a Member s established IFSP or proof of the provider s status as an Early Intervention Program provider shall be requested for review relative to any Request for Treatment. In the absence of an IFSP or Early Intervention Program affiliation by the provider, a denial of requested treatments may occur. Denial of duplicative treatment may occur when documented. 3. In addition, there is a Federal mandate (IDEA) for children between the ages of (3-21) to be evaluated and/or treated in a school-based setting when a Developmental Delay or impairment impacts the child s ability to access the General Education Environment. In these cases, children are entitled to the protections and services identified as part of the Individual Education Plan (IEP), and the child s home school/district shall be the primary Provider and Payer of the required treatment services. Provider requests for treatment services which seek to supplant those services identified and/or authorized by a School/District shall not be authorized, but referred back to the School/District if they are educationally but not medically necessary. Page 10 of 25

11 Page 11 of When applicable, a Member s established IEP shall be requested for review relative to any Request for Treatment. An Attestation that no IEP exists, or that treatments are not being duplicated across multiple Providers or Settings, may also be accepted (see Attachment 1). Coordination of care between School and provider will be established to prevent duplication of services. Services shall not be considered duplicative if child s course of treatment will otherwise be interrupted because it is occurring during school breaks, after school hours, or during summer months. In the absence of an Attestation, a denial of requested treatments may occur when an IEP is available but not provided. Denial of duplicative treatment may occur when documented. 5. Standardized Scores greater than or equal to (1.5) Standard Deviations (SD) below the mean (except where state requirements are more stringent) may qualify as medically necessary as defined by age equivalent/chronological age; however, such a score may not be used as the sole criteria for determining a Member s eligibility for initial or continuing treatment services. 6. Treatment may be approved according to a Member s diagnosed level of severity as long as a clearly documented prognosis is included which establishes the Member s likelihood to develop or recover the anticipated skills or functions (identified as the clinical rationale for initiating or continuing treatment) within a reasonable and medically predictable period of time. Where appropriate, InterQual Criteria will be used as a guideline in the medical necessity decision making process. The frequency of treatment may be approved in accordance with the following: Mild Developmental Delays = Up to 1x per Week Moderate Developmental Delays = Up to 2x per Week Severe Developmental Delays = Up to 3x per Week 7. Any Requests for treatment for Children with less than a 20% documented Developmental Delay, or a Standardized Evaluation Score less than (1.5) Standard Deviations below the mean, shall be referred to the Medical Director or physician designee for final review and determination. 8. A denial of treatment due to a Member s failure to benefit or progress may be made in those cases when a condition or developmental deficit being treated has failed to be ameliorate or effectively treated despite the application of therapeutic Page 11 of 25

12 Page 12 of 25 interventions in accordance with the Member s Plan of Care or if maximum medical benefit has been achieved. 9. Treatment(s) may be re-instituted in accordance with this Policy should a documented regression occur. 10. An examining Physician s Order for treatment or physician s signature on the Plan of Care must accompany all Treatment Requests, regardless of history (Reference attachment A for state specific requirements). Comprehensive Day Rehab (CDR) Authorization Guidelines A. Limitations 1. The member has suffered a recent head injury or traumatic brain injury. Cerebral vascular accidents, aneurysms and congenital deficits are specifically excluded from this definition (Section RSMo). 2. CDR is limited to members who have received a recent traumatic brain injury with identified functional disabilities. Substantial documentation must accompany a Prior Authorization Request for a member who is more than five years post injury. 3. CDR must be rendered by or under the direction or recommendation of a physician who participates in or approves the treatment/rehabilitation plan. 4. CDR must be rendered by an appropriate and qualified head injury professional. Services may be rendered by other professionals when under the supervision of a qualified head injury professional. A qualified head injury professional is either: a. A physician licensed under the state law in which they practice medicine or osteopathy and with training or experience in head injury rehabilitation. b. A psychologist/neuropsychologist licensed under the state law in which they practice psychology, and at least one year s experience in head injury rehabilitation. B. Admission Criteria and Initial Authorization 1. Evidence of an evaluation/assessment 2. Initial authorization for Treatment, following evaluation: Members is clearly diagnosed with a head injury or traumatic brain injury Page 12 of 25

13 Page 13 of 25 The Evaluation team includes individuals with experience in treatment of traumatic brain injury and representing a minimum of two of the following: a. Clinical psychology/neuropsychology b. Occupational therapy c. Physical therapy d. Physician e. Rehabilitation nursing f. Social services g. Speech-language therapy h. Therapeutic recreation i. Rehabilitation counseling j. Education k. Vocational services The Evaluation is signed by a qualified head injury professional and must include all of the following: Clinical Interview with the member and/or family, legal guardian or significant other Screening for necessary neurological assessment or other specialized evaluations A brief history of treatment provided to the Member by the current or most recent Provider Documentation of the member s history and background information A description of the Member s current level of functioning or impairment, and identification of any known primary or secondary health conditions which could impede the Member s ability to benefit from treatment. a. Providers must include the Member s most recent Standardized Evaluation scores, with documentation of age equivalency, percent of functional delay, or Standard Deviation (SD) score when appropriate for the Members diagnosis/disability. Page 13 of 25

14 Page 14 of 25 b. Providers should also include any meaningful clinical observations, summary of a Member s response to the evaluation process, and a brief prognosis statement. Planned treatment modalities, their anticipated frequency and duration. Treatment should include professional services by a minimum of three of the following: a. Psychologist/neuropsychologist b. Speech language pathologist c. Physical therapist d. Occupational therapist e. Vocational rehabilitation specialist f. Education specialist g. Recreational therapist h. Counselor i. Case manager Short and long-term Treatment Goals which are functional, specific to the Member s diagnosed condition or impairment, and measurable relative to the Member s anticipated treatment progress. Documentation of referrals to other medical, professional or community services if necessary All treatment plans and all changes to treatment plans must be approved, signed and dated by the physician. 3. If Services are approved, a communication will be sent to the Provider indicating Approval. Up to three (3) months of treatment may be requested and authorized, when determined medically necessary and the medical prognosis clinically supports the need for up to three (3) months of treatment. C. Continued Authorization 1. Admission criteria is met 2. Submitted documentation includes the following: Page 14 of 25

15 Page 15 of 25 The most current treatment plan Date services were rendered The name and licensure of the person who rendered services The amount of time it took to deliver services to the member Documentation of member s progress Documentation of member s attendance Physician signature on treatment plan D. Discontinuation of CDR 1. Reasons for discontinuing CDR may include, but are not limited to, the following: Member has achieved Treatment Goals as evidenced by one or more of the following: 1. Member no longer demonstrates functional impairment or has achieved goals set forth in the Plan of Care/Treatment Plan 2. Member has returned to baseline function 3. Member will continue therapy with a home therapy program 4. Member s deficits no longer require a skilled therapy intervention 5. Member has adapted to impairment with assistive equipment or devices 6. Member is able to perform ADLs with minimal to no assistance from caregiver Goals can be achieved in a less intensive program Member has reached a functional plateau in progress, or will no longer benefit from additional Therapy Member is unable to participate in the Plan of Care due to medical, psychological, cognitive or social complications Page 15 of 25

16 Page 16 of 25 Non-compliance with and/or lack of participation in scheduled Therapy appointments 2. If Therapy no longer appears to be clinically appropriate and/or beneficial to the Member for any reason, including those identified above, a recommendation for discontinuation should be referred to the Medical Director or physician designee for final review and determination. The American Physical Therapy Association (APTA), Guidelines: Physical Therapy Documentation of Patient/Client Management (2009). ONTENTID=31688 The American Physical Therapy Association (APTA), Criteria for Standards of Practice for Physical Therapy (2009). ontentid=6801 American Speech Language hearing Association, Medical Review Guidelines for Speech- Language Pathology Services (2001). Clark GF. Guidelines for documentation of occupational therapy (2003). Am J Occupational Therapy Nov-Dec;57(6): Standards for Appropriateness of Physical Therapy Care Prepared by the WSPTA Delivery of Care Committee Board Approved 9/26/98; Revised and Board Approved 10/00 at Standards of Practice, the American Occupational Therapy Association. World Confederation for Physical Therapy, Position Statement: Standards of Physical Therapy Practice (2007). Page 16 of 25

17 Page 17 of 25 Comprehensive Day Rehabilitation Manual (Production 05/15/2009). pdf REFERENCES: TIC Section (a) and (b) TX.UM.05 Timelines of UM Decisions and Notifications TX.UM.01 - UM Program Description ATTACHMENTS: 1. Prescription and Verbal Order Timeframes 2. Texas Specific Requirement 3. Louisiana DEFINITIONS: (This information is informational only and not indicative of coverage): Medically Necessary Services: Services or treatments which are prescribed by an examining Physician, or other Licensed Practitioner, and which, pursuant to the EPSDT Program, diagnose or correct or significantly ameliorate defects, physical and mental illnesses, and health conditions, whether or not such services are in the state plan. Physician Signature: The signature of the MD/DO or state approved designee on a Prescription or Request form must be current, on or before the first date of service and no older than the state approved timeframe (see state attachments). Stamped signatures and dates are not accepted. Signatures of Clinical Nurse Specialists or Doctors of Philosophy are not accepted on Authorization Request forms or Prescriptions. Correct or Ameliorate : Means to optimize a Member s health condition, to compensate for a health problem, to prevent serious medical deterioration, or to prevent the development of additional health problems. Coding Implications Multiple codes exist for these services. If needed, exact codes should be obtained from the provider requesting the service. Refer to your State contract for exact coverage implications. Page 17 of 25

18 Page 18 of 25 REVISION LOG REVISION DATE New Policy Entered in Compliance 360. Replaces TX.PAR.31. New therapy policy 10/05/10 approved by Plan Medical Directors. Added TIC language, Healthy Texas, Star+Plus, and CHIP benefits Updated to add South Carolina Language 09/21/11 Update to add Kentucky and Louisiana language. Added criteria for comprehensive day rehabilitation 05/08/12 Created a combined Prescription Requirements Grid (attachment A) 05/08/12 Reviewed and approved by UM Committee 05/29/12 Reviewed by a physical med rehab specialist and deemed medically appropriate 05/30/12 based on medical literature Page 18 of 25

19 Page 19 of 25 POLICY AND PROCEDURE APPROVAL Please sign and date on the lines provided (if applicable): Electronic signature on file 06/20/12 Director, Operations Date Electronic signature on file 06/20/12 Medical Director Date Cenpatico will ensure that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations will be enforced in the application of this policy and procedure if applicable. HIPAA is a Federal regulation established to provide protections for the privacy of an individual s individually identifiable health information. Please see Cenpatico HIPAA Policy & Procedure manual for detail. Page 19 of 25

20 CCL Attachment A Prescription and Verbal Order Timeframes Service Script Requirements Script Time Frame Requirement PT, OT and ST PT/OT Situations when a provider can complete an initial evaluation without prescription Home Health (HH) EPSDT 4 MD, DO, APNP or PA can prescribe therapy in an outpatient setting Exceptions listed below: KY: PT can also be prescribed by DDS, DPM, or DC MO: MD & DO only No script required: LA: PT WA 3 : Referral for initial eval can be made by an authorized health care practitioner. MO: OT MD, DO, APNP or PA can prescribe therapy in a home health setting Exceptions listed below: MO: MD & DO only MD, DO, APNP or PA can prescribe therapy EPSDT services 1 year Exceptions listed below: Texas 1 : 90 days 60 (but can extend to 62 days) Exceptions listed below: Texas: 90 days 6 months Exceptions listed below: Texas: 90 days Verbal Order Time Frame 2 N/A Signature required immediately upon receipt of verbal order. State specific exceptions time frames below: TX 14 days KY 21 days LA 30 days WA 45 days N/A 1 Signatures on Prescriptions or Request forms submitted must be current, on or before the start date, and occur no more than the time frame required amount before the actual date of service. 2 Verbal Orders for Home Health: In some states, the provider can treat under a physician s verbal order. If the request is received within the verbal order time frame, the request must include documentation of the verbal order to include physician name, date of order, and therapies ordered. After the verbal order time frame has been exhausted, the provider must submit a signed prescription with their request for authorization. NOTE: Services provided before the physician signs the plan of care are considered to be provided under a plan established and approved by the physician if there is a verbal order for the care and the request is received within the state specified timeframe. Note: N/A means there is no special provision for verbal orders. 3 PT referral: Direct referral of a patient can be made by an authorized health care practitioner by telephone, letter, or in person. If the instructions are oral, the physical therapist may Page 20 of 25

21 administer treatment accordingly, but must make a notation for his/her record describing the nature of the treatment, the date administered, the name of the person receiving treatment, and the name of the referring authorized health care practitioner. "Authorized health care practitioner" means and includes licensed physicians, osteopathic physicians, chiropractors, naturopaths, podiatric physicians and surgeons, dentists, and advanced registered nurse practitioners. 4 EPSDT: The plan of care needs to be updated every six (6) months to address the changing needs of the child. EPSDT has varying names in each state and may be called something other than EPSDT ; however, the rules and regulations are the same. Page 21 of 25

22 Attachment B: Texas Specific Requirement For CHIP and RSA only: Provision of rehabilitative services or therapies that are medically necessary in the opinion of a physician may not be denied, limited or terminated if the services or therapy meet, or exceed treatment goals for the member. For a member with a physical disability, treatment goals may include maintenance of functioning or prevention of or slowing of further deterioration (TIC Section ). Page 22 of 25

23 Attachment C: Texas Provider Attestation Regarding IEP/IFSP for Outpatient Therapy Services Member Name Member ID Number I have conducted a reasonable review of the facts regarding the therapy services recommended for the above referenced Member, including a discussion with the Parent/Guardian regarding other services that are currently provided. Based upon my review and attestation from the Parent/Guardian, the Member does not have an existing Individualized Educational Plan (IEP) or Individualized Family Service Plan (IFSP). I understand that under my Provider Participation Agreement, Superior Health Plan, and applicable Regulators including the Centers for Medicare and Medicaid Services, and the Texas Health & Human Services Commission or their Representatives, may inspect and evaluate my records related to Members and the provision of and payment for services to audit compliance with this review requirement, and other contractual requirements and Federal and State Laws or Regulations. NOTE: If Member does have an existing IEP or IFSP, it should be submitted, along with the Request for Treatment. Provider Signature Print Name Title Provider Medicaid Identification Number Date Contact Phone Number Page 23 of 25

24 Attachment D: South Carolina In South Carolina physical, occupational, and speech therapy services in an outpatient hospital are reimbursable only under the following conditions: The attending physician prescribes therapy in the plan of treatment during an inpatient hospital stay, and therapy continues on an outpatient basis until that plan of treatment is concluded. The attending physician prescribes therapy as a direct result of outpatient surgery. The attending physician prescribes therapy to avoid an inpatient hospital admission. Therefore, will only be authorized under these conditions. Page 24 of 25

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