Medicaid and OT
Occupational, Physical, and Respiratory Therapy and Speech Pathology Services
The Indiana Health Coverage Program (IHCP) requires Prior Authorization (PA) for all occupational therapy, physical therapy, respiratory therapy, and speech pathology services, with the following exceptions:
- Initial evaluations
- Emergency respiratory therapy
- Any combination of therapy services ordered in writing before a member’s release or discharge from an inpatient hospital, continuing for a period not to exceed 30 units in 30 calendar days
- Deductible and copay or coinsurance for services covered by Medicare Part B
- Oxygen equipment and supplies necessary for the delivery of oxygen, with the exception of concentrators
- Therapy services provided by a nursing facility or large private or small intermediate care facility for individuals with intellectual disabilities (ICF/IID), which are included in the facility’s per diem rate
- Respiratory therapy services ordered in writing for the acute medical diagnosis of asthma, pneumonia, bronchitis, or upper respiratory infection (not to exceed 14 hours or 14 calendar days without PA)
The following PA criteria apply to occupational therapy, physical therapy, respiratory therapy, and speech pathology services:
- The IHCP requires written evidence of physician involvement and personal patient evaluation to document acute medical needs.
- The therapy must be ordered by a qualifying provider, as indicated in the subsections of this module for each type of therapy.
- Providers must attach a current plan of treatment and progress notes indicating the necessity and effectiveness of therapy to the PA request and make this documentation available for audit.
- The therapy must be provided by a qualified therapist, or a qualified assistant under the direct supervision of the therapist, as appropriate.
- The level of complexity and sophistication of the therapy and the condition of the member must be such that the judgment, knowledge, and skills of a qualified therapist are required.
- The therapy must be medically necessary.
- The IHCP does not cover therapy rendered for diversional, recreational, vocational, or avocational purposes; for the remediation of learning disabilities; or for developmental activities that can be conducted by nonmedical personnel.
- The IHCP covers rehabilitative therapy services for members under 21 years of age when determined medically necessary. For members 21 years of age and older, the IHCP covers rehabilitative therapy services for no longer than 2 years from the initiation of the therapy, unless a significant change in medical condition requires longer therapy. Providers can prior authorize respiratory therapy services for a longer period on a case-by-case basis.
- The IHCP covers habilitative therapy services for members under 21 years of age on a case-by-case basis, subject to prior authorization. (Educational services, including, but not limited to, the remediation of learning disabilities, are not considered habilitative therapy and are not covered.) Habilitative therapy is not a covered service for members 21 years of age and older.
- When a member is enrolled in therapy, ongoing evaluations to assess progress and redefine therapy goals are part of the therapy program. The IHCP does not separately reimburse for ongoing evaluations.
- One hour of billed therapy must include a minimum of 45 minutes of direct member care, with the balance of the hour spent in related patient services.
- The IHCP does not reimburse therapy services for more than 1 hour per day per type of therapy; additional therapy services require prior authorization and must be medically necessary.
- The IHCP does not authorize requests for therapy that would duplicate other services provided to a member.
Occupational Therapy Services
For IHCP reimbursement, occupational therapy services must be ordered by one of the following providers:
- Physician (doctor of medicine or doctor of osteopathy)
- Advanced practice registered nurse
- Physician assistant
Occupational therapy services must be performed by a licensed occupational therapist or a licensed occupational therapy assistant under the supervision of a licensed occupational therapist. For IHCP reimbursement to be made, a licensed occupational therapist must perform an evaluation.
The IHCP limits evaluations and reevaluations to 3 hours of service per evaluation.
The IHCP does not cover the following occupational therapy services:
- General strengthening exercise programs for recuperative purposes
- Passive range-of-motion services (as the only or primary mode of therapy)
- Occupational therapy psychiatric services
The IHCP does not reimburse separately for occupational therapy services provided by a nursing facility or a large private or small ICF/IID. These services are included in the facility’s established per diem rate and do not require PA.