Key Changes to TCHP Therapy Authorization Guidelines

When services were not prior authorized by Texas Children’s Health Plan, (through another MCO or TMHP) the authorization request must include:

• A copy of the previously approved authorization letter.
• All of the documentation that was sent in the original authorization request to the previous MCO or TMHP, including any physician orders that were used to determine the start of care.
• If the services requested do not meet TCHP criteria, the services will be honored for the shorter of 90 days or until expiration of the authorization.

For therapy evaluation requests:

• For children with chronic underlying medical condition associated with developmental delay (Autism, Autism Spectrum Disorder, Pervasive Developmental Disorder, Down Syndrome, Cerebral Palsy, etc.) the visit note identifying the need for services should be dated within the last 12 months.  A note from a subspecialist will be accepted.
• For developmental delays or isolated speech/communication/language disorders the visit note identifying the reason for evaluation must be the most recent age-appropriate well child exam including results of the age-appropriate developmental screening tool required by THSteps (PEDS or ASQ) periodicity schedule conducted at the well child visit.  The well child exam must be current per the THSteps periodicity schedule.  If the most recent well child exam did not identify the delay, a provider may submit a subsequent visit that identifies the need for speech therapy
• Screening for hearing loss in children with speech, language or communication delays is considered a best practice.  Results of objective hearing screen performed within the last 6 months for members from birth through 3 years of age or within the last 12 months for members 3 years and older should be submitted with speech therapy evaluation requests.
  • Preferred screening is by pure tone audiometry or OAE in screening mode (65/55 dB)
  • Members who are unable to cooperate with objective hearing screen or who fail the objective hearing screen should be referred for Audiology evaluation. This information should be clearly identified in the authorization request if applicable.
  • Members who fail Audiology evaluation should be referred for medical management. This information should be clearly identified in the authorization request if applicable.
  • When hearing screen results or Audiology consult note is not available at time of initial evaluation request, an authorization for evaluation may be granted but results of the hearing screen or Audiology consult should be submitted with the initial request for treatment.
  • For children with chronic underlying medical condition associated with developmental delay (Autism, Autism Spectrum Disorder, Pervasive Developmental Disorder, Down Syndrome, Cerebral Palsy, etc.), the request for hearing screen may be waived if the initial evaluation request is due to a change in provider or for a referral after service interruption.
  • No hearing screen or audiology referral is required for speech therapy related to dysphagia.

For therapy treatment

• Initial treatment will be honored for 6 months

• We will no longer require proof of most recent well child exam for children without an underlying medical condition who have received services for over 12 months, however ongoing therapy requests should include evidence of attestation that the member’s THSteps checkup is current or that the member’s development has been assessed by the prescribing provider within the last 60 days.

• Order or prior authorization form signed by the referring provider that is dated within 60 days of submission and specifies the frequency and duration of the requested service
  • Frequency and dates of service requested cannot exceed those listed on the provider order and the evaluation plan of care
• Evaluation report and Plan of Care dated within 60 days of submission

When hearing screen results or Audiology consult note were not available at the time of the initial evaluation request for speech therapy, but the evaluation was authorized – the request for initial speech therapy treatment will need to include results of the hearing screen or Audiology consult. If there is a documented barrier to obtaining those results, initial treatment will only be approved for 3 months. Extension of the initial treatment may only be granted with results of the hearing screen or Audiology consult.