Evaluations and Plan of Care Requirements

(A) Initial Evaluation. An initial evaluation is an in-depth assessment of a member’s medical condition or disability, or both, and level of functioning to determine the need for therapy. When therapy is indicated, it is used to develop a plan of care. The evaluation is conducted by a licensed therapist in response to the prescribing provider’s initial prescription for therapy services and must occur prior to the start of therapy care. The MassHealth agency will only pay for one initial evaluation relative to an initial prescription. Documentation of the therapy initial evaluation must include a written report for the member’s medical record that contains at least the following information: (1) the member’s name and address; (2) the member’s diagnosis (specific and relevant to the medical condition requiring therapy services); (3) a list of precautions, if applicable, relevant to the member’s illness, injury, or disability requiring therapy services; (4) a medication list; (5) a detailed treatment plan describing the type, amount, frequency, and duration of therapy and indicating the diagnosis, prognosis, anticipated goals, and location where therapy will take place, or the reason treatment is not indicated; (6) additional health care evaluations, as indicated; (7) a description of the member’s psychosocial and health status that includes: (a) the present effects of the member’s current condition, disability, or injury/illness requiring therapy services; (b) a brief history, the date of onset, and any past treatment of the condition, disability, or injury/illness; (c) the member’s level of functioning, including physical and functional limitations, both current and before onset of the current condition, disability or illness/injury, if applicable; (d) any other significant physical or mental disability that may affect therapy; (e) sensory and cognitive status, if applicable; and (f) social supports, if applicable. (8) identification of any current durable medical equipment (DME) used by the member; (9) identification of any other medical/health services concurrently being provided to the member; (10) a description of any conferences with the member, member’s family, member’s clinician, or other interested persons; (11) a detailed plan of care, which must meet the conditions at 130 CMR 432.416(C); (12) the therapist’s signature and the date of the evaluation; and (13) for speech/language therapy only: (a) assessments of speech production skills; stimulability; receptive and expressive language skills; augmentative and alternative communication skills; fluency; and voice or swallowing; (b) documentation of the member’s cognitive linguistic functioning; and (c) a description of the member’s communication needs and motivation for therapy. (B) Reevaluation. A reevaluation is an evaluation conducted by a licensed therapist focused on determining the member’s progress toward goals identified in the plan of care, as well as making a professional judgment about continuing care, modifying goals and/or treatment, or terminating therapy services. A reevaluation is needed when there are new clinical findings, a rapid change in the individual’s status, or a member’s inability to respond to therapy interventions. Routine, ongoing progress notes that are part of each therapy visit are not considered reevaluations. (C) Plan of Care. All therapy services must be provided under a plan of care established individually for the member. The plan of care must include the following: (1) a description of the type of therapy, location where therapy will take place, anticipated frequency, length of each visit, and an estimate of the duration of the therapy services; (2) documentation of the diagnosis, prognosis, anticipated goals, functional and measurable short- and long-term goals, and the reason therapy is needed; and (3) dated signature of the licensed therapist who developed the plan of care. The plan of care must be reviewed and updated at least every 60 days with the renewal of the prescription for therapy services, and more frequently as the member’s condition or needs require, including any significant change that may alter the type, frequency, or duration of therapy services.