Provider Alert! : Initial Specialty Therapy Evaluations no longer require an Authorization

Provider Alert!

Provider Alert! : Initial Specialty Therapy Evaluations no longer require an Authorization

Effective Date: September 1, 2019

Call to action: Initial specialty therapy (occupational, physical, speech therapy) evaluations do not require prior authorization effective September 1, 2019.
How this impacts providers:

In an effort to ensure our in-network providers can provide specialty therapy evaluations within 21 days of submission of a signed referral, Texas Children’s Health Plan (TCHP) will no longer require prior authorization for in-network specialty therapy evaluations billed within the guidance of the current Texas Medicaid Provider Procedure Manual (TMPPM).

Next steps for providers:

The provider will be responsible for maintaining the following documentation in the member record, which must be made available when requested:

  • A signed and dated prescribing provider’s order for the evaluation
  • Clinical documentation that identifies and supports the medical need for the therapy evaluation

All therapy treatment will continue to require prior authorization and must meet criteria in the TCHP Guidelines for Speech Therapy, Occupational Therapy, and Physical Therapy.  Guidelines are available in our provider portal and upon request.

Initial speech therapy treatment will continue to require submission of the results of objective hearing screening for approval.  For children with chronic underlying medical condition associated with developmental delay (e.g. Autism, Autism Spectrum Disorder, Pervasive Developmental Disorder, Down Syndrome, Cerebral Palsy, etc.). The request for a hearing screen may be waived if the initial evaluation request is due to a change in provider, a referral after service interruption or if there is a medical barrier to obtaining a hearing screen.

Providers should continue to bill for therapy services in accordance with guidance in the current TMPPM Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook Section 5.5.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

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