Provider Alert! Amended: Initial and Ongoing Specialty Therapy Treatment

Provider Alert!

Provider Alert! Amended: Initial and Ongoing Specialty Therapy Treatment

Date: September 19, 2019
Attention: All Providers
Subject:  Amended:  Initial and Ongoing Specialty Therapy Treatment- Current Texas Health Steps Checkup or Attestation required
Effective Date: September 19, 2019

Call to action: Initial specialty therapy (occupational, physical, speech therapy) evaluations do not require prior authorization effective September 1, 2019. However, a current Texas Health Steps checkup performed in the last 12 months or a current well checkup attestation is required for ongoing specialty therapy lasting for greater than 60 days.

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).

Effective 9/18/19 Providers will need to have a copy of a Texas Health Steps Checkup performed in the last 12 months or a well checkup attestation.

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.

Providers should submit a copy of current Texas’s Health Steps checkup or attestation of current Texas Health Steps check up with all initial and ongoing therapy requests.

Acute physical, occupational and speech therapy treatment (60 days or less) requests will not require current well checkup or attestation.

  • Until 12/31/19 therapy treatment requests received without current Texas’s Health Steps checkup or attestation will be approved for a maximum of 90 days if all other therapy criteria are met.
  • Continued therapy treatment will require current Texas’s Health Steps checkup or attestation.
  • As of 1/1/20 initial and ongoing therapy treatment authorization will require current Texas’s Health Steps checkup or attestation for approval.

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.

Texas Children’s Health Plan Guidelines for Speech Therapy, Occupational Therapy, and Physical Therapy are available in our provider portal and upon request.

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

For access to all provider alerts, log into:
www.thecheckup.org or https://www.texaschildrenshealthplan.org/for-providers

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