Physical, Occupational, and Speech Therapy Services
(TX.CP.MP.549)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Section I, M moved from I.L.2 to its own distinct criteria
- Section III additional language added to Note “As the member’s medical need for therapy decreases, it is expected that the therapy frequency will decrease as well”
- Section III B and C updated “12 weeks” to “120 days”
- Section II, B move from 1. to first paragraph “Therapy provided two times a week may be considered when documentation shows that the member is making meaningful functional progress towards therapy goals and shows one or more of the following”
- Section III C added “but the progress has slowed”
- Section III added “Maintenance Therapy may not exceed 2 visits per month”
- Added Section IV I “Member shows a plateau in response to therapy and/orlack of progress towards therapy goals. This is an indication for a therapeutic pause in treatments or, for member’s age 20 years of age and younger, transition to chronic status and maintenance therapy”
- Added Section V. B “Speech therapy provided in the home to adult clients who are 21 years of age and older”
- Added to Section X, B. 3 “The evaluation/assessment must be completed within 60 days of the date the prior authorization request is received”
- Added Section X.B.3 xi, xii and xiv in it’s entirety
- Added Section X,C, b. and c
- Added clarifying language “evaluating and re-evaluating” to Section X
- Added Note to Section X, C, b
- Restructured Section X, C, 4 to “Therapy goals must target a member-specific functional outcome written in the S.M.A.R.T. format (Specific, Measurable, Attainable, Relevant and Time-based) that could only be addressed by a skilled therapist”
- Added Section X, C, 8 through 13 with a note in its entirety
- CPT code list added for potential PT, OT and ST services
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- Policy
- Policy Criteria
- It is the policy of Superior HealthPlan that speech therapy, occupational therapy, and physical therapy evaluation and treatment services are considered medically necessary when all the following criteria are met:
- The member must be clinically stable and exhibit 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
- Integumentary deficits
- Member and caregiver must be committed to program participation
- The treatment is ordered by the member’s PCP (physician or allowed practitioner) or appropriate specialist and formal evaluation is conducted by a licensed speech, occupational, or physical therapist
- There is an expectation that within a reasonable and medically predictable period of time the treatment will produce clinically significant and measurable improvement in the member’s level of functioning and prevent or delay further decline
- The treatment program must be individualized and measured by members’ progress in achieving anticipated goals or maintenance outcomes
- The treatment requires the judgment, knowledge, and skills of a licensed speech, occupational, or physical therapist, or therapy assistant (SLPA, COTA or PTA)
- In determining whether a service requires the skill of a licensed physical, occupational, or speech therapist, consideration must be given to the inherent complexity of the service, the condition of the member, and the accepted standards of medical and therapy practice guidelines
- Services provided must be within the provider’s scope of practice, as defined by state licensure law and regulatory compliance. Physical therapy may be provided by a physician or physical therapist within their licensed scope of practice
- The treatment cannot be reasonably learned and implemented by non-professional or lay caregivers
- 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
- The treatment does not duplicate services provided by other types of therapy or services provided in multiple settings
- If treatment is part of a medically necessary program to maintain function or prevent significant functional regression, the following criteria must be met:
- Must include clearly stated maintenance goals directed at a skilled service
- Must be a skilled service that could not reasonably be carried out by a lay person. The absence of a competent person to perform the service does not cause it to become a skilled service
- Therapy services must be performed by one of the following: a licensed physical therapist, licensed occupational therapist, licensed speech-language pathologist, a physician within their scope of practice, or one of the following under the supervision of a licensed therapist of the specific discipline:
- Licensed therapy assistant
- Licensed speech-language pathology intern (Clinical Fellow)
- Not Medically Necessary:
- It is the policy of Superior HealthPlan that speech therapy, occupational therapy, and/or physical therapy evaluation and treatment services are considered not medically necessary when:
- A service that is not skilled is requested.
- Note: A service is considered not skilled if the service can safely and effectively be performed by the average non-medical person without the direct supervision of a licensed therapist
- The members’ function would not be expected to improve as the member gradually resumes normal activities
- Frequency and Duration of Therapy Services (PT,OT,ST)
- Frequency must always be commensurate with the member’s medical and skilled therapy needs, level of disability, and standards of practice; it is not for the convenience of the member or the responsible adult
- Therapy requests above these limits will be reviewed by a medical director on a case-by-case basis
- Note: Frequency and duration requests should be individualized for the member with consideration of the member’s condition and potential to benefit from the formulated treatment plan. As the member’s medical need for therapy decreases, it is expected that the therapy frequency will decrease as well
- High Frequency – duration up to 4 weeks
- High frequency (3 times per week) can only be considered for a limited duration (approximately 4 weeks or less) or as otherwise requested by the prescribing provider with documentation of medical need to achieve an identified new skill or recover function lost due to surgery, illness, trauma, acute medical condition, or acute exacerbation of a medical condition, with well-defined specific, achievable goals within the intensive period requested
- Therapy provided three times a week may be considered for two or more of these exceptional situations:
- The member has a medical condition that is rapidly changing
- The member has potential for rapid progress (e.g., excellent prognosis for skill acquisition) or rapid decline or loss of functional skill (e.g., serious illness, recent surgery)
- The member’s therapy plan and home program require frequent modification by the licensed therapist
- On a case-by-case basis, a high frequency requested for a short-term period (4 weeks or less) which does not meet the above criteria may be considered with all of the following documentation:
- Letter of medical need from the prescribing provider documenting the member’s rehabilitation potential for achieving the goals identified; and
- Therapy summary documenting all of the following:
- Purpose of the high frequency requested (e.g., close to achieving a milestone)
- Identification of the functional skill which will be achieved with high frequency therapy
- Specific measurable goals related to the high frequency requested and the expected date the goals will be achieved
- A higher frequency (4 or more times per week) may be considered on a case-by-case basis with clinical documentation supporting why three times a week will not meet the member’s medical needs
- Moderate Frequency – duration up to 120 days for acute conditions or duration not to exceed 180 days, for chronic conditions
- Therapy provided two times a week may be considered when documentation shows that the member is making meaningful functional progress towards therapy goals and shows one or more of the following:
- The member is in a critical period to gain new skills or restore function and is at risk of regression
- The licensed therapist needs to adjust the member’s therapy plan and home program weekly or more often than weekly based on the member’s progress and medical needs
- The member has complex needs requiring ongoing education of the responsible adult
- Low Frequency – duration up to 120 days for acute conditions or duration not to exceed 180 days, for chronic conditions
- Therapy provided one time per week or every other week may be considered when the documentation shows one or more of the following:
- The member is making meaningful functional progress toward therapy goals, but the progress has slowed, or the member is nearing discharge where tapering of treatment would be appropriate
- Documentation shows the member is at risk of deterioration without therapeutic intervention due to the member’s developmental or medical condition
- The licensed therapist is required to adjust the member’s therapy plan and home program weekly to every other week based on the member’s progress
- Every other week therapy is supported for members whose medical condition is stable, they are making progress, and it is anticipated the member will not regress with every other week therapy
- Maintenance Level/Prevent Deterioration – duration not to exceed 180 days
- Maintenance Therapy may not exceed 2 visits per month
- For members who are 20 years of age and younger or STAR+PLUS Waiver members, this frequency level (e.g., every other week, monthly, every 3 months) is used when the therapy plan changes very slowly, the home program is at a level that may be managed by the member or the responsible adult, or the therapy plan requires infrequent updates by the skilled therapist. A maintenance level or preventive level of therapy services may be considered when a member requires skilled therapy for ongoing periodic assessments and consultations, and the member meets one of the following criteria:
- Progress has slowed or stopped, but documentation supports that ongoing skilled therapy is required to maintain the progress made or prevent deterioration
- Documentation shows the member and the responsible adult have a continuing need for education, a periodic adjustment of the home program, or regular modification of equipment to meet the member’s needs
- Note: The reference to “maintenance” in the above statement is applicable to members who are 20 years of age and younger or for STAR+ waiver members
- Criteria For Discontinuation of Therapy Services
- May include, but are not limited to, one or more of the following:
- Member no longer demonstrates functional impairment or has achieved goals set forth in the plan of care
- Testing shows member no longer has a developmental delay
- Member has returned to baseline function
- Member can continue therapy with a home treatment program and deficits no longer require a skilled therapy intervention to maintain status
- Member has adapted to impairment with use of compensatory strategies or assistive equipment/devices.
- Member is able to perform ADLs with minimal to no assistance from caregiver
- Member has achieved maximum functional benefit from therapy or is no longer expected to benefit from additional therapy based upon lack of or minimal progress towards therapy goals
- Member is unable to participate in the treatment plan due to medical, psychological, or social complications and responsible adult has had instruction on the home treatment program and the skills of a therapist are not needed to provide or supervise the service
- Member shows a plateau in response to therapy and/orlack of progress towards therapy goals. This is an indication for a therapeutic pause in treatments or, for member’s age 20 years of age and younger, transition to chronic status and maintenance therapy
- Non-compliance due to poor attendance with member or responsible adult, and/or non-compliance with therapy and home treatment program
- Therapy no longer appears to be clinically appropriate or beneficial to the member for any reason, including those identified above, a recommendation for discontinuation (denial) should be referred to the medical director for final review and determination
- A historical review of all relevant member documentation does not show functionally beneficial services, progression of therapy goals or goals are repetitive
- During the denial period, consideration of new requests for the same condition by the same servicing provider would be required to follow the appeals process documented on the Letter of Adverse Determination. If the member has a new illness, injury or true exacerbation of their medical condition, a new request may be considered when objective documentation of the change in medical status is submitted
- Exclusions (Non-Covered Services)
- Not all treatment modalities are Texas Medicaid/CHIP benefits. Coverage of specific modalities depends upon their proven efficacy, safety, and medical appropriateness as established by accepted and discipline-specific practice standards
- The following services are not a benefit of Texas Medicaid/CHIP under this policy:
- Therapy services that are provided after the member has reached the maximum level of improvement or is now functioning within normal limits
- Speech therapy provided in the home to adult clients who are 21 years of age and older
- Repetitive therapy services that are designed to maintain function once the maximum level of improvement has been reached, which no longer require the skills of a therapist to provide or oversee
- Therapy services related to activities for the general good and welfare of members are not considered medically necessary because they do not require the skills of a therapist, such as:
- General exercises to promote overall fitness and flexibility
- Activities to provide diversion or general motivation
- Supervised exercise for weight loss
- Instruction of English as a second language
- Treatment of behavioral issues as a replacement for behavioral therapy
- Hippotherapy, equine therapy, and therapeutic riding are not covered benefits and may not be billed in conjunction with speech, occupational, or physical therapy services
- Massage therapy that is the sole therapy and is not part of a comprehensive therapeutic treatment plan to address an acute condition
- Separate reimbursement for VitalStim® therapy for dysphagia is not medically necessary. VitalStim® must be a component of a comprehensive feeding treatment plan to be considered a benefit
- Treatment solely for the instruction of other agency or professional personnel in the member’s PT, OT, or ST program
- Emotional support, adjustment to extended hospitalization or disability, and behavioral readjustment.
- Therapy not expected to result in practical functional improvements in the member's level of functioning
- Treatments that do not require the skills of a licensed therapist to perform in the absence of complicating factors (i.e., massage, general range of motion exercises, repetitive gait, activities and exercises that can be practiced by the member on their own or with a responsible adult’s assistance)
- Therapy requested for general conditioning or fitness, or for educational, recreational or work-related activities that do not require the skills of a therapist
- Therapy equipment and supplies used during therapy visits are not reimbursed separately; these would be considered part of the therapy services provided.
- Therapy prescribed primarily as an adjunct to psychotherapy
- Treatments not supported by medically peer reviewed literature, including, but not limited to, investigational treatments such as sensory integration, vestibular rehabilitation for the treatment of attention deficit hyperactivity disorder, anodyne therapy, craniosacral therapy, interactive metronome therapy, cranial electro stimulation, low-energy neuro-feedback, and the Wilbarger brushing protocol
- Therapy services provided by a licensed therapist who is the member’s responsible adult (e.g., biological, adoptive, foster parent, guardian, court-appointed managing conservator, or other family members by birth or marriage)
- Auxiliary personnel (aide, orderly, student, or technician) may participate in physical therapy, occupational therapy, or speech therapy sessions when they are appropriately supervised according to each therapy discipline’s scope of practice and provider licensure requirements
- Children’s Therapy Services: Members birth through 20 years of age
- Acute PT, OT, and ST Services
- Acute PT, OT, and ST services are benefits of Texas Medicaid for the medically necessary short term treatment of an acute medical condition or an acute exacerbation of a chronic medical condition
- Treatments are expected to significantly improve, restore, or develop physical functions diminished or lost as a result of a recent trauma, illness, injury, disease, surgery, or change in medical condition, in a reasonable and generally predictable period of time, based on the prescribing provider’s and therapist’s assessment of the members’ restorative potential
- Note: Recent is defined as occurring within the past 90 days of the prescribing provider’s evaluation of condition
- Treatments are directed towards restoration of, or compensation for, lost function
- Acute is defined as an illness or trauma with a rapid onset and short duration
- A medical condition is considered chronic when 120 days have passed from the start of therapy, or the condition is no longer expected to resolve or may be slowly progressive over an indefinite period of time
- With documentation of medical need, physical, occupational, and speech therapy may continue for a maximum of 120 days for an acute medical condition or an acute exacerbation of a chronic medical condition
- Once the member’s condition is no longer considered acute, continued therapy for a chronic condition will only be considered for members who are 20 years of age or younger
- Chronic Services
- Chronic physical, occupational, and speech therapy services are benefits of Texas Medicaid for the medically necessary treatment of chronic medical conditions and developmental delay when a medical need is established for the developmental delay. All eligible members who are birth through 20 years of age may continue to receive all medically necessary therapy services, with documentation proving medical necessity
- The goals of the services provided are directed at maintaining, improving, adapting, or restoring functions which have been lost or impaired due to a recent illness, injury, loss of body part, congenital abnormality, degenerative disease, or developmental delay
- Treatment for chronic medical conditions and developmental delay will only be considered for members who are birth through 20 years of age
- Developmental Delay Criteria Using Standardized Testing
- Standardized Tests must be age-appropriate for the member. Providers should use the same testing instrument utilized in the initial evaluation when deemed appropriate. If reuse of the initial testing instrument is not appropriate (i.e. due to change in member status, restricted age range of the testing instrument, or the instrument is no longer a valid means of testing), the provider must explain the reason for selecting a different method of assessment
- If standardized testing is not appropriate for a member, a description of the member’s current functional deficits and their severity level may be documented using objective data. Documentation may include current age equivalents, and percentage of functional delay, criterion-referenced scores or other objective information as appropriate for the member’s condition or impairment
- When a standardized test is documented, standardized scores greater than or equal to one-and-a-half standard deviations (SD) below the mean (except where state requirements are more stringent) may indicate medical necessity when considered in conjunction with the overall treatment plan and stated functional goals
- One and a half SD below the mean for a standardized test wherein the mean is 100 would equal a standard score of 78
- Adjusting Score for Children with a History of Prematurity
- From birth to 24 months of age, impairments in development must be determined based on the member's corrected age as calculated using the member's gestational age at birth and not on the member’s actual age at the time of the testing. Full term is considered 40 weeks. Correct age in weeks is calculated by subtracting the number of weeks the member was premature from the number of weeks of the member's actual age. For example: if a member was born at 28 weeks gestation, the member is 12 weeks (3 months) premature. If the member is now 48 weeks old (12 months old), his corrected age is 48 weeks minus 12 weeks or 36 weeks (9 months old). This member's development may be expected to be on par with a 9-month-old rather than a 12-month-old
- Additional treatment plan documentation for speech therapy requests
- The member's language knowledge and exposure must be established through a thorough case history and relevant caregiver interview
- The documentation must include all of the following that apply:
- Home language(s)
- School, daycare and community language(s) of instruction or exposure
- If child is exposed to more than one language, an appropriate assessment of speech and language abilities should be performed
- If no standardized tool is available, then results should be reported using appropriate objective assessment methods. Examples may include criterion-referenced tests, probes, language samples, dynamic assessment, or MLU, etc. in order to differentiate a language disorder from a language difference as well as the severity of that disorder, should it be identified
- 4. If a standardized bilingual language test is utilized as part of the objective assessment, documentation of its type of administration must be stated for either dual language administration or monolingual administration use only
- Adult Services: Benefits and Limitations
- Physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are benefits of Texas Medicaid for the medically necessary short-term treatment of an acute medical condition or an acute exacerbation of a chronic medical condition for members who are 21 years of age and older
- Treatments are expected to significantly improve, restore, or develop physical functions diminished or lost as a result of a recent trauma, illness, injury, disease, surgery, or change in medical condition, in a reasonable and generally predictable period of time based on the prescribing provider’s and therapist’s assessment of the member’s restorative potential
- Note: Recent is defined as occurring within the past 90 days of the prescribing provider’s evaluation of condition
- Treatments are directed towards restoration of, or compensation for, lost function
- Acute is defined as an illness or trauma with a rapid onset and short duration
- Adult therapy services are limited to a maximum of 120 days per identified acute medical condition or acute exacerbation of a chronic medical condition requiring therapy or whenever the maximum benefit from therapy has been achieved, whichever comes first
- A medical condition is considered chronic when 120 days have passed from the start of therapy, or the condition is no longer expected to resolve or may be slowly progressive over an indefinite period of time
- Physical and occupational therapy services for acute conditions are benefits of Texas Medicaid for adult members in the office, outpatient, and home settings
- Speech therapy services for acute conditions are benefits of Texas Medicaid for adult members in the office and outpatient setting only
- STAR+PLUS Waiver Members/Home and Community Based Services (HCBS) Program
- Therapy services provided through the STAR+PLUS Home and Community Based Services (HCBS) program are long term services (waiver benefit) and do not replace a member’s acute care benefit. Therapy services include the evaluation, examination and treatment of physical, functional and speech disorders and limitations. Therapy services include the full range of activities under the direction of a licensed therapist within the scope of her or his state licensure. Therapy services are provided directly by licensed therapists or by assistants under the supervision of licensed therapists in the member's home, or the member may receive the therapy in an outpatient center or clinic
- Occupational therapy (OT), physical therapy (PT), and speech therapy (ST) are covered by the STAR+PLUS HCBS program (waiver benefit) only after the member has exhausted her or his therapy benefit under Medicare, Medicaid or other third-party resources (TPRs)
- STAR+PLUS Nursing Facility (NF) Add-On Services
- Acute OT, PT and ST are covered benefits of the nursing facility add-on services. These services may not be covered under the nursing facility daily unit rate. Medicaid nursing facility members may not be eligible for Medicare or other insurance. These services will not be processed for members that are dual eligible (have both Medicare and Medicaid) unless member is enrolled in Superior’s STAR+PLUS Plan
- Coverage for physical therapy, occupational therapy, or speech therapy services includes evaluation and treatment of functions that have been impaired by acute illness or exacerbation of a chronic illness or condition only
- Rehabilitative services may be provided when there is an expectation that the member’s functioning will improve measurably within 30 days
- The provider must ensure that rehabilitative services are provided under a written treatment plan based on the physician's diagnosis and orders and services are documented in the member's clinical record
- Documentation of services must conform to the requirements outlined within this policy
- Documentation Requirements for PT, OT and ST Services
- Initial ST Evaluation Authorization
- Requests for initial ST evaluation must include:
- A speech therapy evaluation order signed and dated within the last 60 days of the prior authorization request, by the member’s PCP (physician or allowed practitioner ) or other appropriate specialist involved in the member’s care
- Prior Authorization dates of service, which can span up to 90 days
- Documentation supporting medical necessity must be provided in one of the following formats:
- Texas Health Step visit note that is current per periodicity schedule
- Office exam note within the last 60 days
- Physicians Order within the last 60 days
- For members 5 years of age and younger, documentation of a hearing screening performed per the TH-Steps Periodicity Schedule. The hearing screen may be performed by a Speech-Language Pathologist who has appropriate training
- Hearing Screening is defined as a test administered with a pass/fail result for the purpose of rapidly identifying those persons with possible hearing impairment which has the potential of interfering with communication. If the member failed a hearing screening, either due to behavioral issues, inability to participate in the hearing screen or due to suspected hearing deficit, the following documentation would be expected:
- In the case of behavioral issues or inability to participate in the hearing screen, an objective description of the behavioral issues and/or inability to participate in the hearing screen along with a statement as to why hearing deficit is not suspected; or
- In the case of suspected hearing deficit, a referral to an audiologist or physician who is experienced with the pediatric population and who offers auditory services would be appropriate. Documentation of such a referral must be included in the clinical documentation submitted
- Note: If an auditory assessment has not occurred prior to the start of speech therapy, the speech therapy treatment plan must address the suspected hearing loss
- For evaluations addressing feeding only, a hearing screening is not required
- Note: ST re-evaluations do not require prior authorization for in-network providers
- Initial Treatment Authorization for PT, OT and ST Services
- Initial authorization for therapy treatment must include a treatment plan
- The treatment plan must be signed and dated by the member’s PCP (physician or allowed practitioner) or appropriate specialist. In lieu of having the treatment plan signed, the provider may submit a physician referral or order signed and dated the day of the evaluation or after, specifying the frequency and duration of the requested service
- The treatment plan must also be signed and dated by the evaluating therapist. Physical Therapist Assistants, Certified Occupational Therapy Assistants and Speech-Language Pathology Assistants may not sign evaluation/assessment regardless if the PT, OT or SLP co-signs.
- The evaluation/assessment must be completed within 60 days of the date the prior authorization request is received
- The treatment plan must document:
- Member’s age
- A brief statement of the member’s medical history, including onset date of the illness, injury, or exacerbation that requires the therapy services and any prior therapy treatment
- Relevant review of systems
- Pertinent physical assessment including a description of the member’s current functional deficits and their severity level documented using objective data
- Note: Documentation may include current standardized assessment scores, age equivalents, and percentage of functional delay, criterion-referenced scores or other objective information as appropriate for the member’s condition or impairment
- A clear diagnosis and reasonable prognosis including the member’s potential for meaningful and significant progress
- A description of the member’s functional impairment with a comparison of prior level of function to current level of function, when applicable
- A statement of the prescribed treatment modalities and their recommended frequency and duration
- Proposed patient and caregiver education
- Therapy goals must target a member-specific functional outcome written in the S.M.A.R.T. format (Specific, Measurable, Attainable, Relevant and Time-based) that could only be addressed by a skilled therapist
- Therapy goals written with targets set for achievements specific to standardized testing benchmarks will not be accepted. Therapy goals must relate to the member’s specific functional skills. Goals should not be treatment activities
- The services requested must be of a level of complexity or the patient’s condition must be such that the services required can only be effectively performed by or under the supervision of a licensed occupational therapist, physical therapist, or speech-language pathologist, and requires the skills and judgment of the licensed therapist to perform education and training
- Meaningful/Functional goals refer to a series of behaviors or skills that allow the client to achieve an outcome relevant to his/her health, safety, or independence within the context of everyday environments. Functional goals must be specific to the client, objectively measurable within a specified time frame, attainable in relation to the client’s prognosis or developmental delay, relevant to client and family, and based on a medical need
- If the treatment plan/evaluation is part of a medically necessary program to maintain or prevent a significant functional regression, it must document skilled services to be provided and have therapy goals that address maintenance. Therapy maintenance programs are a benefit for members under 21 years of age or HCBS program (waiver) members
- When therapy is initiated, the therapist must provide education and training of the client and responsible caregivers, by developing and instructing them in a home treatment program to promote effective carryover of the therapy program and management of safety issues
- Additional requirements for speech therapy treatment requests include:
- Language evaluations – should include oral-mechanism examination and objective assessment of hearing, speech production, voice, and fluency skills
- Speech production - should include objective assessment of language skills, hearing, voice, and fluency skills
- Oral motor, swallowing and feeding - if swallowing, feeding problems or signs of aspiration are noted as a concern, then a complete objective, clinical-bedside swallow evaluation is expected, as per ASHA standards for both pediatric and adult dysphagia. The member’s language, speech, hearing, voice and fluency skills must also be addressed in the assessment via a screen or objective testing
- Continued Authorization for PT, OT and ST Services
- Progress toward therapy goals must be clearly documented in an updated treatment plan/re-evaluation or current progress summary. This documentation must be submitted by the servicing provider at the end of each authorization period or when additional visits are being requested
- The treatment plan must be signed and dated by the member’s PCP (physician or allowed practitioner) or appropriate specialist. In lieu of having the treatment plan/re-evaluation signed, the provider may submit a physician referral or order signed and dated the day of the evaluation or after, specifying the frequency and duration of the requested service
- The treatment plan must also be signed and dated by the evaluating therapist. Physical Therapist Assistants, Certified Occupational Therapy Assistants and Speech-Language Pathology Assistants may not sign progress notes or re-evaluations regardless if the PT, OT or SLP co-signs
- The re-evaluation/assessment must be completed within 60 days of the date the prior authorization request is received
- Documentation must include the following:
- Number of therapy visits authorized and number of therapy visits attended
- A clear diagnosis and reasonable prognosis including the member’s potential for meaningful and significant progress
- A description of the member’s current functional deficits and their severity level documented using objective data. This may include current standardized assessment scores, age equivalents, percentage of functional delay, criterion-referenced scores, or other objective information as appropriate for the member’s condition or impairment
- Objective demonstration of the member’s progress towards each prior therapy goal
- Therapy goals are developed by the evaluating therapist to be met within the timeframe specified on the treatment plan/re-evaluation
- If any goals are unmet, it is the evaluating therapist’s responsibility to objectively describe specific barriers to progress that were encountered and make appropriate modifications to the treatment plan/re-evaluation in order to meet the member’s needs.
- Note: a member’s diagnoses/conditions at the time of the prior assessment and goal development would not be considered a barrier to progress
- For all unmet therapy goals, report the status of the goal at the beginning of the previous treatment period, and the current status at the time of reporting using the same terms, variables, and targets as the original goal as they compare to the targets
- If the treatment plan/re-evaluation was written with maintenance goals, a status statement would be expected for each maintenance goal directed at a skilled service
- An updated statement of the prescribed treatment modalities and their recommended frequency and duratio
- A clear, member specific prognosis with established discharge criteria
- A description of the member’s functional impairment with a comparison of prior level of function to current level of function, when applicable
- Therapy goals must target a member-specific functional outcome written in the S.M.A.R.T. format (Specific, Measurable, Attainable, Relevant and Time-based) that could only be addressed by a skilled therapist
- Therapy goals written with targets set for achievements specific to standardized testing benchmarks will not be accepted. Therapy goals must relate to the member’s specific functional skills. Goals should not be treatment activities
- The services requested must be of a level of complexity or the patient’s condition must be such that the services required can only be effectively performed by or under the supervision of a licensed occupational therapist, physical therapist, or speech-language pathologist, and requires the skills and judgment of the licensed therapist to perform education and training
- Meaningful/Functional goals refer to a series of behaviors or skills that allow the client to achieve an outcome relevant to his/her health, safety, or independence within the context of everyday environments. Functional goals must be specific to the client, objectively measurable within a specified time frame, attainable in relation to the client’s prognosis or developmental delay, relevant to client and family, and based on a medical need
- When ongoing therapy is requested, the therapist must provide documentation that education and training was provided to the client and responsible caregivers, by developing and instructing them in a home treatment program to promote effective carryover of the therapy program and management of safety issues
- Additional requirements for speech therapy treatment requests include:
- Language evaluations – should include oral-mechanism examination and objective assessment of hearing, speech production, voice, and fluency skills
- Speech production - should include objective assessment of language skills, hearing, voice, and fluency skills
- Oral motor, swallowing and feeding - if swallowing, feeding problems or signs of aspiration are noted as a concern, then a complete objective, clinical-bedside swallow evaluation is expected, as per ASHA standards for both pediatric and adult dysphagia. The member’s language, speech, hearing, voice and fluency skills must also be addressed in the assessment via a screen or objective testing
- Note: If a request for Initial ST Evaluation or PT/OT/ST Treatment is incomplete, inconsistent, or unclear Superior Healthplan will contact the servicing or ordering provider to request additional or clarifying documentation to enable Superior Healthplan to make a decision on the request
- Change of Provider
- If a therapy provider discontinues services during an existing prior authorization period and the member requests service through a new provider, the following must be submitted:
- Change of provider letter signed by the member or member’s caregiver
- Documents the date the member ended therapy (effective date of change) with the previous provider
- Names of the previous and new treating providers.
- A member may request the discharge summary from the previous provider be submitted with the request for therapy
- Treatment Notes
- Documentation of all therapy evaluations, re-evaluations and daily notes must be kept on file by the treating provider and be available upon request. This documentation must be legible and include:
- Member's name
- Date of service
- Time in and out of each therapy session
- Objectives addressed (must coincide with treatment plan) and progress noted, if applicable
- Description of specific skilled therapy services provided and the activities rendered during each therapy session, along with a form of measurement
- Member’s response to treatment
- Assessments of the member’s progress or lack of progress
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- Discharge Planning
- Discharge planning is for a maximum duration of up to 14 calendar days, depending upon the extent of therapeutic needs. Requests beyond 14 calendar days are not appropriate for discharge planning and should be submitted as a standard request with all necessary documentation
- Discharge planning for therapy (PT/OT/ST) is medically necessary with all of the following:
- Submission of a discharge order from the hospital (signed prescription, discharge paperwork, electronic or verbal order) with the following:
- Therapeutic modality (PT/OT/ST), and
- Duration (not to exceed 14 calendar days), and
- Appropriate diagnosis for requested therapy discipline, and
- Note: Diagnosis may include but are not limited to:
- For members aged 21 years of age and older: orthopedic surgeries, cerebrovascular accident (CVAs), neurological conditions, coronary artery bypass grafting (CABG), cardiac surgeries, debilitation from long hospital stays, and/or home safety evaluation
- For members under 21 years of age: feeding issues, orthopedic issues, neurological conditions, and/or home safety evaluation
- Requested frequency does not exceed 6 encounters/visits per discipline, for a maximum duration of 14 calendar days
- Speech therapy up to 6 encounters;
- Physical therapy/occupational therapy up to 6 visits/24 units
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