Covered Occupational Therapy Services

Covered Occupational Therapy Services A. The Division of Medicaid covers occupational therapy services in the outpatient setting when medically necessary, ordered by a physician, physician assistant or nurse practitioner, and prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or a designated entity to treat a beneficiary’s illness, condition, or injury and the following requirements are met: 1. The services require the knowledge, skill and judgment of a state-licensed occupational therapist. 2. The Certificate of Medical Necessity (CMN) for initial referral/order is completed by the prescribing provider prior to the occupational therapy evaluation. 3. The plan of care (POC) is developed by a state-licensed occupational therapist. 4. The prescribing provider approves the initial/revised POC with a signature and date: a) Before the initiation of treatment or change in treatment, or b) Within thirty (30) calendar days of the verbal order for the initial treatment plan or change in treatment. 5. The services are rendered as individualized therapy, consistent with the symptomatology/diagnosis and do not exceed the beneficiary’s needs. 6. The services do not duplicate another provider’s services including those services provided in a school-based setting. B. The Division of Medicaid reimburses for covered occupational therapy services provided by: 1. A state-licensed occupational therapist. 2. A state-licensed occupational therapist assisted by a state-licensed occupational therapist assistant under direct, on-site supervision by a state-licensed occupational therapist. a) The Division of Medicaid defines direct, onsite supervision as face-to-face oversight by a state-licensed occupational therapist at regular intervals, as prescribed by the standards of the Accreditation Council of Occupational Therapy Education (ACOTE) and does not include: 1) Contacts by telephone, 2) Contacts by pager, 3) Video conferencing, and/or 4) Any method not approved by the Division of Medicaid. b) The initial evaluation, POC, and discharge summary must be completed by a state-licensed occupational therapist. 3. A state-licensed occupational therapist assisted by an occupational therapy student who is enrolled in an accredited occupational therapy program while completing the clinical requirements necessary for graduation under direct, on-site supervision of a state-licensed occupational therapist, referred to as student assisted occupational therapy services. a) The Division of Medicaid defines direct, on-site supervision of an occupational therapy student as the face-to-face oversight by a state-licensed occupational therapist. b) The state-licensed occupational therapist must be physically present and engaged in student oversight during the entirety of a therapy session such that the state-licensed occupational therapist is considered to be providing the occupational therapy service. C. The state-licensed occupational therapist cannot supervise at the same time during the work day more than: 1. One (1) occupational therapy student, 2. A total of four (4) state-licensed occupational therapist assistants, or 3. One (1) occupational therapy student and three (3) state-licensed occupational therapist assistants.