Rehabilitative and Therapeutic Services Authorization Criteria

Revised: July 11, 2014

Authorization Criteria

Effective July 1, 2013, medical authorization is no longer required for outpatient rehabilitative and therapeutic services; physical therapy, occupational therapy and speech-language pathology. MHCP suspended authorization requirements from July 1, 2011 to July 1, 2013. Rehabilitative and therapy services are subject to post-payment review and may result in a particular provider being required to request authorization for certain services.

Audiology services: For recipients who require services in excess of the annual service threshold, additional medically necessary services are available with authorization.

Authorization is not a guarantee of payment. An authorization request may be done prospectively or retroactively and requests may also include authorization of both prospective units of anticipated services and retroactive authorization of services already provided.

Providers are responsible for submitting authorization requests in a timely manner. When providers determine, in the course of providing rehabilitative services, that additional units of service are needed, they are urged to submit authorization requests prospectively, anticipating needed services for the recipient. However; there is no requirement to submit authorization prior to delivering service unless the provider is an out-of-state provider.

Examples:

· Therapist receives physician order to “evaluate and treat.” Provider performs the evaluation as per physician order/referral. In the course of performing the evaluation, a treatment plan is determined. The provider submits the authorization request for the evaluation units (retroactive authorization) and prospectively requesting authorization of units of service needed for the treatment plan.

· Providers are encouraged to request service units needed to deliver the treatment plan.

Submit the following legible, photocopied material, in chronological order with the authorization form. Only send requested documentation, not the entire file.

Authorizations for recipients with third party liability (TPL)
Providers must meet any third party payer criteria, including accreditation requirements for the third party insurance or Medicare, in order to assist recipients for whom MCHP is not the primary payer. Providers who do not meet the third party payer’s or Medicare’s requirements must refer the recipient to a provider who does. MHCP will not reimburse providers who do not meet provider criteria for the primary payer, whether a third party insurer or Medicare.

Except for home care authorization requests, authorization is not required if a third party payer has made payment that is equal to or greater than 60% of the MHCP maximum allowed amount for the service/item. Submit the claim to MHCP and attach the EOB from the other payer(s) to the claim. See also Medicare and Other Insurance.

Initial Authorization
Documentation matching requested services and demonstrating the reasons the skills of an occupational therapist, physical therapist or speech-language pathologist is required, including:

· Physician’s (or practitioner of the healing arts) current order/prescription

· Initial evaluation with:

· Identified problems

· Treatment diagnosis and date of onset, including any contraindications to treatment

· Summary of previous episodes of therapy

· Current and prior functional status, including baseline evaluation and brief past and current medical history

· All tests performed and interpretation of results

· Plan of Care: All POC from the origin of services

· Additional documentation may be requested for authorizations to establish medical necessity, including clarification of carry-over therapeutic interventions such as in-home programs, school programs (rehabilitative services provided as part of an Individualized Education Plan (IEP)), employment and other settings, such as:

· School programs, including frequency and goals: With signed parental consent, outpatient rehabilitative service providers are encouraged to coordinate therapy services with school therapists

· Community and home programs

· Treatment notes: 60 days if applicable

Authorizations for Ongoing Services

· Re-eval, if applicable, including summary of progress

· POC, every 60 days; send all signed POCs since previous authorization

· Treatment notes with verification of units provided since last authorization

Retro Authorizations, in addition to the documentation listed above, include:

· Initial evaluation/re-evaluation

· POC, every 60 days from start of care

· Origin and rationale for referral, including a copy of order or prescription

· Documentation demonstrating when function was lost

· Treatment notes for time period requested

· Verification of units delivered (charge logs)

Authorization for Therapy Groups
Include the following information with authorization requests for therapy groups:

· Description of the purpose of the group

· Duration of each session

· Specifics of medical necessity

· Number of group sessions requested; and

· All items under Initial Evaluation and Plan of Care

Authorization for Service/Supplies for Casting and Strapping
Refer to the Casting & Strapping Services/Supplies chart. Include the following information with authorization requests for casting and strapping:

· Brief history indicating medical necessity

· Itemized statement of supplies

Authorization Termination
MHCP will terminate reimbursement when services are discontinued by the referral source or when the recipient has:

· Met the goals of the POC

· Developed behavioral or vocational problems that are not being addressed and that interfere with return to work or the ability to participate in therapy (particularly pediatric cases)

· Failed to comply with the requirements of participation

· Developed medical contraindications

· Reached a plateau prior to meeting goals

Legal References

MS 256B.0625 subd. 8, 8a., 8b., 8c., and 31a. Covered Services
Minnesota Rules 9505.0390 Rehabilitative and Therapeutic Services
Minnesota Rules 9505.0391 Therapists Eligible to Enroll as Providers
Minnesota Rules 9505.0392 Compliance With Medicare Requirements
Minnesota Rules 9505.0412 Required Documentation of Rehabilitative and Therapeutic Services
Minnesota Rules 9505.5010 Prior Authorization