SC Medicaid Announces Limitations on Therapy Services

This is an update to the January 31, 2011, Medicaid bulletin which addresses the requirements for additional units request for Private Rehabilitative Therapy Services (speech-language pathology, occupational, and/or physical therapy). Individuals under age 21 will require prior approval once they have reached a combined total of 75 hours (300 units) per fiscal year. The hours used as of April 1st will count toward this checkpoint for the fiscal year ending June 30. The state fiscal year begins July 1st and ends June 30th of each year.

 

To receive payment for services that exceed the frequency checkpoint there must be documentation of medical necessity as well as a pre-approval (PA) by the South Carolina Department of Health and Human Services (SCDHHS). Effective immediately, the request letter from the Primary Care Physician (PCP) must contain the following:

 

• PCP’s clinical office notes, preferably an EPSDT exam, from the recipient’s visit not to exceed 60 days prior to the date of the PA request

 

• number of units needed for the remainder of the fiscal year

 

• diagnosis and/or functional impairment that establishes medical necessity

 

• specific therapy or therapies requested (PT, OT, ST)

 

• the Medicaid ID number of the recipient

 

• therapist’s notes which include an evaluation overview, proposed treatment plan with expected outcomes, and relative progress notes.

 

Documentation must be faxed to SCDHHS at 803-255-8222, Attention Private Rehabilitative Therapy Services Authorization, prior to providing the additional rehabilitative therapy service that exceeds the 75 hour checkpoint. Failure to comply with these requirements will delay the approval process.

 

This policy only applies to Private Rehabilitative Therapy Services. These checkpoints do not apply to School-Based Rehabilitative Therapy Services provided under the Individuals with Disabilities Education Act (IDEA) which are exempt from the yearly frequency checkpoint. There are different criteria for therapy provided as an Outpatient Hospital Service which must not be used to circumvent this process.

 

For beneficiaries enrolled in a Managed Care Organization (MCO), please refer to the individual MCO plan regarding their services.

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