Provider Alert! Update: Acute Therapy Requests with treatment for less than 60 days, a Texas Health Steps Checkup or Attestation is Not RequiredTexas Children's Health Plan
Effective Date: October 31, 2019
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 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 from a visit for the acute injury within the last 90 days
All therapy treatment will continue to require prior authorization and must meet criteria in the Texas Children’s Health Plan Guidelines for Speech Therapy, Occupational Therapy, and Physical Therapy. Guidelines are available in our provider portal and upon request.
Ordering Providers should submit a copy of current Texas Health Steps checkup or attestation of current Texas Health Steps check up with all initial and ongoing therapy requests for services greater than 60 days. If evidence that the member is current in their Texas Health Steps Checkup is not submitted, therapy requests may be approved for a maximum of 90 days with medical director approval.
After two 60-day authorized periods, any continued requests for therapy services must be considered under the chronic therapy section of the applicable guideline.
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.
Acute speech therapy services with an out-of-network provider must comply with TCHP’s Out of Network Services Guidelines.
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: firstname.lastname@example.org
For access to all provider alerts, log into:
www.thecheckup.org or https://www.texaschildrenshealthplan.org/for-providers