Prior Authorization/Precertification

Prior Authorization/Precertification A. Medicaid requires prior authorization/precertification for certain outpatient therapy services. 1. Prior authorization/precertification for therapy services is conducted through the Utilization Management and Quality Improvement Organization (UM/QIO). 2. Failure to obtain prior authorization/precertification will result in denial of payment to the providers billing for services. 3. The UM/QIO must determine medical necessity for the types of therapy services and the number of units reasonably necessary to treat the beneficiary’s condition. The frequency of visits provided by the therapist must match the Plan of Care signed by the physician. B. Prior Authorization/Precertification for outpatient therapy services is only required for certain codes when the services fall into one (1) of the following categories: 1. Therapy services provided to beneficiaries in individual therapist offices or in therapy clinics, 2. Therapy services provided to adult beneficiaries in the outpatient department of hospitals, 3. Therapy services provided to beneficiaries in physician offices/clinics, 4. Therapy services provided to beneficiaries in nursing facilities, 5. Therapy services covered under regular benefits and provided to beneficiaries also enrolled in a Home and Community-Based Services (HCBS) waiver program, 6. Therapy services provided to beneficiaries covered under both Medicare and Medicaid, if Medicare benefits have exhausted, or 7. Therapy services billed by school providers. C. Prior Authorization/Precertification is not required, when the services fall into one (1) of the following categories: 1. Therapy services provided to beneficiaries in an ICF/MR, 2. Therapy services provided to beneficiaries in a Private Nursing Facility for the Severely Disabled (PNFSD), 3. Therapy services provided to beneficiaries enrolled in a hospice program, or 4. Therapy services provided to beneficiaries covered under both Medicare and Medicaid if Medicare benefits have not exhausted, D. Medicaid will cover the initial evaluation and first (1st) therapy session on the same day, when medically necessary.