STAR, STAR+PLUS* and CHIP Clinical Policies Effective December 1, 2021: Outpatient Rehabilitative and Habilitative Therapy Services
Date: 10/28/21
Clinical policies ensure medical necessity review criteria are current and appropriate for members and within the scope of services provided. Beginning December 1, 2021, National Imaging Associates, Inc. (NIA) will be performing utilization review of outpatient physical, occupational, and speech therapy treatment services for Superior Medicaid (STAR, STAR+PLUS*) and CHIP members. The following NIA policies are effective on December 1, 2021 at 12:00AM.
*Please note: Medicaid STAR+PLUS non-Home and Community Based Services (HCBS) Waiver members ONLY. Providers should continue to obtain authorization for STAR+PLUS HCBS Waiver services through Superior HealthPlan on and after December 1, 2021.
POLICY | APPLICABLE PRODUCTS | POLICY OVERVIEW |
|---|---|---|
Active Procedures in Physical Medicine | Medicaid (STAR, STAR+PLUS Non-Waiver), and CHIP | Description: This policy provides guidelines to assist the evidence based physical medicine provider to properly choose the correct service(s) when indicated for proper overall case management. |
Experimental, Unproven, or Investigational Services | Medicaid (STAR, STAR+PLUS Non-Waiver), and CHIP | Description: This policy will be used to provide a listing of procedures considered experimental, investigational by any physical medicine practitioner, including chiropractors, physical therapists, occupational therapists, and speech language pathologists. Services listed in the policy are not eligible for reimbursement. |
Measurable Progressive Improvement | Medicaid (STAR, STAR+PLUS Non-Waiver), and CHIP | Description: This policy will be used to provide minimal clinical thresholds using specific measurable, and functional treatment goals and/or outcome measures in the determination of improved, lasting, and sustained outcomes. These thresholds will assist in medical necessity reviews of billed clinical services by network practitioners. |
Outpatient Habilitative Physical and Occupational Therapy | Medicaid (STAR, STAR+PLUS Non-Waiver), and CHIP | Description: This policy includes the clinical documentation criteria for physical and occupational therapy treatment services. |
Outpatient Habilitative and Rehabilitative Speech Therapy | Medicaid (STAR, STAR+PLUS Non-Waiver), and CHIP | Description: This policy includes the clinical documentation criteria for speech therapy treatment services. |
Passive Treatment | Medicaid (STAR, STAR+PLUS Non-Waiver), and CHIP | Description: This policy provides a list of procedures and modalities considered to be passive treatment, the appropriate use of passive treatment, and when passive treatment is considered clinically appropriate and/or necessary. |
Plan of Care | Medicaid (STAR, STAR+PLUS Non-Waiver), and CHIP | Description: This policy provides the elements required in the documentation of a provider's plan of care. |
Record Keeping and Documentation Standards | Medicaid (STAR, STAR+PLUS Non-Waiver), and CHIP | Description: This record keeping policy outlines the general clinical documentation guidelines for acute versus chronic conditions, frequency and duration and goal writing criteria in order to support the submission for review, in a timely manner. |
To review NIA policies, please visit NIA’s Clinical Medicine Clinical Guidelines webpage. contact NIA at 1-800-642-7554.
For expansion details and provider training opportunities, please review: STAR, STAR+PLUS* and CHIP Utilization Review for Outpatient Rehabilitative and Habilitative Therapy Services through National Imaging Associates Effective December 1, 2021