Therapy Program

PURPOSE: This rule establishes the regulatory basis for the administration of the therapy program. This rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available through the MO HealthNet program as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. Specific details of provider participation, criteria, and methodology for provider reimbursement, participant eligibility, and amount, duration, and scope of services covered are included in the therapy provider program manual, which is available at the website www.dss.mo.gov/mhd. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Administration. The MO HealthNet therapy program shall be administered by the Department of Social Services, MO HealthNet Division. The therapy services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the Therapy Provider Manual, which is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/collections/collection_the/print. pdf, January 31, 2023. This rule does not incorporate any subsequent amendments or additions. Therapy services shall include only those which are clearly shown to be medically necessary as determined by the physician, advanced practice registered nurse, or other practitioner of the healing arts. The division reserves the right to effect changes in services, limitations, and fees with notification to therapy providers by amending this rule. (2) Participants Eligible. Medically necessary therapy services as determined by the physician, advanced practice registered nurse, or other practitioner of the healing arts are covered for individuals under the age of twenty-one (21). The Healthy Children and Youth (HCY) Program (also known as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)) ensures a comprehensive, preventive health care program for MO HealthNet eligible children under the age of twenty-one (21) years. The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that MO HealthNet-covered services be provided, based on medical necessity as identified in a HCY (EPSDT) well-visit and interperiodic screening. These services include physical, occupational, and speech/language therapy services. The participant must be eligible on the date the service is furnished. Participants may have specific limitations to therapy program services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the Therapy Provider Manual. The provider shall ascertain the patient’s MO HealthNet status before any service is performed. The participant’s eligibility shall be verified in accordance with methodology outlined in the therapy provider program manual. (3) Provider Participation. (A) To be eligible for participation in the MO HealthNet therapy program, a provider must meet the criteria specified for his or her profession as outlined in the therapy provider program manual and be an enrolled MO HealthNet provider. (B) To be eligible for participation in the MO HealthNet therapy program as a therapy assistant, a provider must be licensed according to state law and provide services under the direction of a qualified therapist. (C) The enrolled MO HealthNet provider shall agree to— 1. Keep any records necessary to disclose the extent of services the provider furnishes to participants; and 2. On request furnish to the Department of Social Services or state Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan. (4) Covered Services. The participant shall have a referral for speech therapy services from a MO HealthNet-enrolled physician, advanced practice registered nurse, or other practitioner of the healing arts. The participant shall have a prescription for occupational and physical therapy services from a MO HealthNet-enrolled physician, advanced practice registered nurse, or other practitioner of the healing arts. (5) Reimbursement. Payment will be made in accordance with the established fee as defined and determined by the MO HealthNet Division. Providers must bill their usual and customary charge for therapy services. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charges. Physical, occupational, and speech therapy services are only payable to the enrolled, eligible, participating provider. The MO HealthNet program cannot reimburse for services performed by non-enrolled persons. (6) Documentation. For physical, occupational, and speech therapy services, the MO HealthNet Division requires compliance with 13 CSR 70-3.030 and that the following documentation be included in the participant’s record: (A) First name, last name, and either middle initial or date of birth of the MO HealthNet participant; (B) Date the service was provided (month/day/year); (C) An accurate, complete, and legible description of each service(s) provided for the participant (more than “treatment given”) on the specific date of service; (D) Individual or group therapy (the provider must document the type of therapy given); (E) The actual begin and end time taken to deliver the service must be clearly documented in the client record (e.g., 4:00–4:15 p.m.); providers cannot bill for charting time, only the time they spend doing the therapy; (F) The signature of the enrolled therapist or enrolled therapy assistant who provided the service; (G) The official Individual Education Plan (IEP) or Individual Family Services Plan (IFSP) which must be in the record when billing therapy with a WQ modifier; (H) The setting in which the service was rendered; and (I) The plan of treatment, evaluation(s), test(s), findings, results, and prescription(s) as necessary. (7) Records Retention. Sanctions may be imposed by the Department of Social Services against a provider for failing to make available, and disclosing to the Department of Social Services or its authorized agents, all records relating to services provided to MO HealthNet participants or records relating to MO HealthNet payments, whether or not the records are commingled with non-Title XIX (Medicaid) records in compliance with 13 CSR 70-3.030. These records must be retained for six (6) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation. AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016.* Original rule filed Nov. 1, 2002, effective May 30, 2003. Amended: Filed June 1, 2006, effective Dec. 30, 2006. Amended: Filed Oct. 15, 2008, effective May 30, 2009. Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed July 16, 2021, effective Feb. 28, 2022. Amended: Filed March 2, 2023, effective Oct. 30, 2023. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.