Prior Authorization/ Precertification

Prior Authorization/ Precertification A. The UM/QIO will determine medical necessity, 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 prescribing provider. B. Prior Authorization/Pre-certification for outpatient therapy services is only required for certain procedure codes when the services fall into one (1) of the following categories: 1. Therapy services provided to beneficiaries, adult and/or children in individual therapist offices or in therapy clinics, 2. Therapy services provided to beneficiaries, adult and/or children, in the outpatient department of hospitals, 3. Therapy services provided to beneficiaries, adult and/or children, in physician offices/clinics, 4. Therapy services provided to beneficiaries in nursing facilities, 5. Therapy services covered under regular State Plan benefits and provided to beneficiaries also enrolled in a Home and Community-Based Services (HCBS) waiver program, and 6. Therapy services provided to beneficiaries covered under both Medicare and Medicaid if Medicare benefits have been exhausted. C. Exclusions to Prior Authorization/Precertification 1. Prior Authorization/Precertification is not required, regardless of procedure codes used, when the services fall into one (1) of the following categories: a) Therapy services provided to beneficiaries in an ICF/MR, b) Therapy services provided to beneficiaries in a Private Nursing Facility for the Severely Disabled (PNFSD), c) Therapy services provided to beneficiaries enrolled in a hospice program, or d) Therapy services provided to beneficiaries covered under both Medicare and Medicaid if Medicare benefits have not been exhausted. D. Prior Authorization/Pre-certification Request - Processes related to certification and recertification of therapy services must be handled in accordance with the procedures set forth by the UM/QIO.