Prior Authorization for Therapy (OT, PT, ST) Updates Effective November 1, 2013

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1 Prior Authorization for Therapy (OT, PT, ST) Updates Effective November 1, 2013 SHP_ B

2 The following guidelines are effective November 1, 2013, and may be referenced in Superior HealthPlan s Policy and Procedure governing Physical, Occupational and Speech Therapy Services, reference number TX.UM

3 Requesting Prior Authorization Requests for prior authorization of therapy services can be made by phone, fax, or web by contacting Superior at: Phone: Fax: Web: Turn-around times for prior authorization requests are 3 business days for Medicaid members and 2 business days for CHIP members. Requests submitted with missing information may delay processing. As we are unable to provide authorization for retroactive dates of service, prior authorization requests must be submitted no later than the day the requested service is to begin. Optimally, we recommend submitting requests 5 business days prior to the desired start date in order to allow time for processing.

4 Prior Authorization Requirements Prior authorization is required for all therapy services, to include: Initial evaluations Reevaluations Initial treatment services Ongoing treatment services Initial evaluation and reevaluation requests must originate from the office of the PCP or other pertinent physician Treatment requests (initial or ongoing) may originate from either the office of the PCP or the therapy provider Note: ECI services do not require prior authorization.

5 How Will the Process Change After November 1, 2013? What Stays the Same: 1) The physician writes an evaluation order and gathers any needed supporting documentation. 2) Upon receipt of the prior auth request, Superior staff fax a confirmation sheet with reference number to the requestor. 3) If the request is incomplete, Superior will request additional information. 4) The PCP will supply any additional needed documentation from the member s medical chart. What Changes: Instead of sending the order and other documents to the fax number of the therapy provider along with a referral form, the physician will send that information to the fax number of Superior HealthPlan along with a prior auth request form. Instead of only faxing to the requesting agency, Superior staff will now send a confirmation fax to both the physician and the therapy agency upon receipt of the request. Instead of requesting additional information from the therapy agency, and then that agency relaying the request to the physician so that additional documentation can be obtained, Superior will request any additional documentation directly from the physician. Instead of faxing additional information from the member s chart to the therapy provider, and then the therapy provider faxing that information to Superior, the physician will fax the information directly to Superior. 5) If a status update is desired during the time the request is pending with Superior, that information may be obtained by either the physician or the therapy agency. 6) Once authorized, an approval letter will be issued via fax. Instead of sending the approval fax only to the therapy provider, Superior staff will send the approval to both the therapy provider and the requesting physician. N/A

6 Common Questions Regarding the 11/01/13 Change Why is Superior making this change? We believe that having the physicians act as originators for therapy evaluation and reevaluation requests will streamline the submission process greatly. Feedback from both therapy providers and physicians has indicated that when the therapy provider acts as the submitting party, this places them in the role of middle man and adds an unnecessary step to the process. Additionally, physicians continue to report that they feel a loss of oversight of the therapy referral process. How can providers get additional information or guidance if they feel they need it? How can providers give feedback or suggestions regarding the process? Please contact your provider relations representative with any questions, needs or feedback regarding this process. If you do not know who your PR representative is, please call us at (800) and someone will help you. Will provider feedback really make a difference? Absolutely. We routinely implement process improvements or changes as a result of input from our network providers.

7 Initial Evaluation Requests Requirements for prior authorization: An evaluation order which must specify the discipline(s) to be evaluated and have been signed (and dated) by the physician within the last 30 days. For members under age 21, a copy of the most recent THSteps exam (or wellness visit), which must be current as specified by the THSteps periodicity schedule. For members under age 6, evidence of developmental screening performed by the PCP within the last 30 days, demonstrating significant concerns in the area to be evaluated (speech, gross motor, fine motor, etc.). The ASQ or the PEDS are recommended, as they are the screening tools required at intervals by the THSteps program.

8 Initial Evaluation Requests (cont.) For speech therapy evaluation requests age 6 and under, documentation of a recent hearing screening, as follows: Must be current within the last six months for members birth to 3 years of age. Must be current within the last twelve months for members 3 years, 1 month to 6 years, 0 months of age. May be performed as a component of the THSteps exam. Per the THSteps Medical Checkup Periodicity Schedule, subjective hearing screening is recommended through age 3; audiometric screening is required at age 4 and after. A copy of the Periodicity Schedule may be accessed via the provider information section of the Texas HealthSteps web site, located here: and is also pictured on the following slide.

9 Initial Evaluation Requests (cont.)

10 Initial Evaluation Requests (cont.) If the member has failed the hearing screening, results of a full audiological assessment must also be submitted, to include documentation of treatment for any hearing loss that has been identified. Hearing screening is not required when speech therapy evaluation is requested to assess feeding/swallowing functions only. The hearing screening requirement applies only to speech therapy requests pertaining to communication (language, articulation, etc.). Superior also makes available a summary template which allows physicians to capture all of the required developmental and screening information on one form. The Patient Wellness Summary can be accessed at: 112_1.pdf

11 Common Questions Regarding Initial Evaluations Who are the pertinent physicians other than the PCP who may initiate the request for therapy? Presently, accepted physician specialists include: neurologist, orthopedic physician, rehabilitation physician, sports medicine physician, developmental/neurodevelopmental pediatrician, otolaryngologist (ENT) and plastic surgeon (when the referral is related to a craniofacial anomaly or related condition). What about physician designee signatures? For members under age 21 with Medicaid coverage, an APRN or PA may sign all documentation related to the provision of therapy services when this authority is delegated by the physician. Are the ASQ and the PEDS the only developmental screenings Superior will accept? No. The ASQ and PEDS are recommended because these are the screenings required at intervals by the THSteps program. Superior will accept results of any standardized, professionally recognized screening tool. What if the member has already had his/her checkup? Can physicians bill for another developmental screening? Yes. Physicians may bill an exception to periodicity using the SC modifier, indicating medical necessity due to suspected developmental delays.

12 Reevaluation Requests Requirements for prior authorization: A reevaluation order which must specify the discipline(s) to be reevaluated and have been signed (and dated) by the physician within the last 30 days. Documentation identifying medical necessity for the reevaluation, if the reevaluation is to be performed greater than 30 days prior to the end of the existing treatment authorization. If the reevaluation is to be performed within 30 days of the end of the existing treatment authorization, no medical necessity documentation will be needed.

13 Common Questions Regarding Reevaluations What are some reasons a reevaluation might be medically necessary during the course of therapy treatment? Generally, when reevaluation is to take place for a purpose other than determining continued eligibility for services, it is in response to a significant change of status on the part of the member, such as a major illness, recent surgery, accident or trauma, etc. What about physical therapists, who are required to reassess their patients monthly? All requests for prior authorization will be considered on the basis of medical necessity. While ECPTOTE does require monthly PT reevaluations, this requirement does not automatically cause that reevaluation service to become medically necessary. Furthermore, ECPTOTE specifies only that reassessment must take place via a face to face visit during which the PT reviews the plan of care for appropriate continuation, revision or termination of treatment. If it is determined to be medically necessary that this take the form of a formal reevaluation visit, rather than, for instance, via information that can be gathered during the course of a regularly scheduled treatment visit, this medical necessity information should be provided at the time of the request.

14 Treatment Requests Requirements for prior authorization: A treatment order which must specify the frequency and duration of the requested service and have been signed (and dated) by the physician within the last 90 days, either on or after the date the most recent evaluation was performed A brief statement of the member s medical history and any prior therapy treatment A description of the member s current level of functioning or impairment, to include current standardized assessment scores, age equivalents, percentage of functional delay, or criterion-referenced scores as appropriate for the member s condition or impairment A clear diagnosis and reasonable prognosis A statement of the prescribed treatment modalities and their recommended frequency/duration Short- and long-term treatment goals which are specific to the member s diagnosed condition or impairment

15 Treatment Requests (cont.) If the request is for reauthorization of ongoing treatment, documentation must also include: Objective demonstration of the member s progress toward each prior treatment goal An explanation of any changes to the member s plan of care, and the clinical rationale for revising the plan

16 Common Questions Regarding Treatment Requests Does the therapist have to do a formal reevaluation every time they request treatment? What about if the last authorization was only for 3 months? The therapist will need to report objective data in order to show continuance of medical necessity for treatment, however it is the responsibility of the clinician to determine what type of objective information will need to be obtained in order to fully document each member s current functional status, on an individual basis. There may be times that the therapist determines a formal reevaluation is unnecessary, as sufficient objective data for demonstration of medical necessity can be collected in the course of the member s regularly scheduled treatment session, without administration of formal assessment measures. Should treatment visits be requested per week (e.g., 2x/week) or per month (e.g., 8x/month)? Either is acceptable. Superior staff will calculate and authorize the approved visits/units in the manner they are requested, provided the request is supported by appropriate physician treatment orders.

17 Common Questions Regarding Treatment Requests How is medical necessity determined? Is it by test scores alone? No. Superior s clinicians are trained to consider all pieces of objective information in making recommendations regarding medical necessity. How should progress be documented for ongoing treatment requests? Progress should be documented by providing objective information which demonstrates a change in the member s ability to perform the skills targeted within the plan of care. To do this, the clinician will need to report the baseline or previous functional status with respect to each goal, in comparison to the current functional status. Why can t test scores alone be considered an indicator of progress in treatment? Particularly in the area of pediatrics, most members would be anticipated to continue developing some skills over the course of a three- to sixmonth period, even if no intervention were provided. Therefore, it is important to ascertain whether changes in the member s abilities are due to the natural effects of development and maturation, or due to the treatment that has been provided. This can only be determined by examining whether or not the member has progressed in the specific skill areas that were targeted throughout the course of treatment.

18 Acute/Urgent/Emergent Care Needs Members experiencing acute medical conditions (e.g., a broken leg) and those with some major medical diagnoses will be excepted from the requirement for current THSteps exam and developmental screening for initial evaluation requests. Regarding urgent/emergent therapy services, we anticipate the need to be limited. With that said, we will continue to follow our urgent/emergent preauthorization process. The standard preauthorization form may be faxed with a physician signature indicating the services are urgent/emergent. When this occurs following hospital discharge, the physician signature can be that of the hospital treating physician. These requests are processed within 24 hours. Note: Please do not write or check off the word urgent on prior authorization requests as a routine part of the request process. This designation should be reserved for truly medically urgent needs.

19 Provider References For additional information, please refer to: The initial provider notification letter issued by mail on 07/29/13 and via on 08/06/13. Therapy Prior Authorization FAQ located at: pdf?9f4dba. Texas Health Steps Quick Reference Guide located at: 3.pdf?9f4dba. Clinical Practice Standards for Therapy Documentation located at: py pdf?9f4dba Superior HealthPlan Provider Manual located at:

20 Thank you for your participation in Superior HealthPlan s network of providers. We value your partnership in our mission to provide comprehensive medical care to our members. Please contact Superior HealthPlan with any questions about the information presented here. We can be reached by calling (877) , option 3.