405 IAC 5-22-6 - Occupational, physical, and respiratory therapy and speech pathology; criteria for prior authorization
Current through March 30, 2022
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 6.
(a) Prior
authorization is required for all therapy services with the following
exceptions:
(1) Initial
evaluations.
(2) Emergency
respiratory therapy.
(3) Any
combination of therapy ordered in writing prior to a member's discharge from an
inpatient hospital that may continue for a period not to exceed thirty (30)
units in thirty (30) calendar days.
(4) The deductible and copay for services
covered by Medicare, Part B.
(5)
Oxygen equipment and supplies necessary for the delivery of oxygen with the
exception of concentrators.
(6)
Therapy services provided by a nursing facility or large private or small
intermediate care facility for individuals with intellectual disabilities
(ICF/IID), which are included in the facility's per diem rate.
(7) Respiratory therapy ordered in writing by
a physician to treat an acute medical condition, except as required in section
10 of this rule.
(b)
Unless specifically indicated otherwise, the following criteria for prior
authorization of therapy services apply to occupational therapy, physical
therapy, respiratory therapy, and speech pathology:
(1) Written evidence of physician involvement
and personal patient evaluation will be required to document the acute medical
needs. A current plan of treatment and progress notes, as to the necessity and
effectiveness of therapy, must be attached to the prior authorization request
and available for audit purposes.
Therapy must be ordered by one (1) of the following provider types:
(A) For physical therapy, the
order must come from a physician (doctor of medicine or doctor of osteopathy),
podiatrist, psychologist, chiropractor, dentist, nurse practitioner, or
physician assistant holding an unlimited license to practice medicine,
podiatric medicine, psychology, chiropractic, dentistry, nursing, or as a
physician assistant.
(B) For
occupational therapy, the order must come from a physician (doctor of medicine
or doctor of osteopathy), podiatrist, advanced practice nurse, psychologist,
chiropractor, optometrist, or physician assistant.
(C) For respiratory therapy and speech
pathology, the order must come from a physician (doctor of medicine or doctor
of osteopathy).
(2)
Therapy must be provided by a qualified therapist or qualified assistant under
the direct supervision of the therapist as appropriate.
(3) Therapy must be of such a level of
complexity and sophistication and the condition of the member must be such that
the judgment, knowledge, and skills of a qualified therapist are
required.
(4) Medicaid
reimbursement is available only for medically necessary therapy.
(5) Therapy rendered for a diversional,
recreational, vocational, or avocational purpose, or for the remediation of
learning disabilities or for developmental activities that can be conducted by
nonmedical personnel, is not covered by Medicaid.
(6) This subdivision applies to services for
recipients twenty-one (21) years of age and older. Therapy for rehabilitative
services will be covered for a member twenty-one (21) years of age and older
for no longer than two (2) years from the initiation of the therapy unless
there is a significant change in the member's medical condition requiring
longer therapy. Habilitative therapy is not a covered service for members
twenty-one (21) years of age and older. Respiratory therapy services are
covered for members twenty-one (21) years of age and older but for no longer
than two (2) years from the date of initiation of the therapy. Respiratory
therapy may be covered for a longer period of time on a case-by-case basis
subject to prior authorization.
(7)
This subdivision applies to services for members under twenty-one (21) years of
age. Therapy for rehabilitative services will be covered for a member under
twenty-one (21) years of age when determined to be medically necessary.
Habilitative therapy services for members under twenty-one (21) years of age
will be covered on a case-by-case basis and are subject to prior authorization.
Educational services, including, but not limited to, the remediation of
learning disabilities, are not covered by Medicaid.
(8) When a member is enrolled in therapy,
ongoing evaluations to assess progress and redefine therapy goals are part of
the therapy program. Ongoing evaluations are not separately reimbursed by
Medicaid.
(9) One (1) hour of
billed therapy service must include a minimum of forty-five (45) minutes of
direct patient care with the balance of the hour spent in related patient
services.
(10) Reimbursement for
therapy services is limited to one (1) hour per day per type of therapy.
Additional therapy services must be medically necessary and requires prior
authorization.
(11) A request for
therapy services, which would duplicate other services provided to a member,
will not be prior authorized. Therapy services will not be authorized when such
services duplicate nursing services required under 410 IAC
16.2-3.1-17.
Notes
The following state regulations pages link to this page.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.