Prescribing Provider Orders/Responsibilities

Prescribing Provider Orders/Responsibilities A. Medicaid provides benefits for therapy services that are medically necessary, as certified by the prescribing provider. B. The prescribing provider must complete a Certificate of Medical Necessity for Initial Referral/Orders form and submit it to the therapist prior to therapy evaluation. C. Therapy services must be furnished according to a written plan of care (POC). The plan of care must be approved by the prescribing provider before treatment is begun. Medicaid defines approval as the prescribing provider has reviewed and agreed with the therapy plan. The review can be done in person, by telephone, or facsimile. An approved plan does not mean that the prescribing provider has signed the plan prior to implementation, only that he/she has agreed to it. The plan of care must be developed by a therapist in the discipline. A separate plan of care is required for each type of therapy ordered by the prescribing provider. The plan must, at a minimum, include the following: 1. Beneficiary demographic information, 2. Name of the prescribing provider, 3. Dates of service, 4. Diagnosis/symptomatology/conditions and related diagnosis codes, 5. Reason for referral, 6. Specific diagnostic and treatment procedures/modalities and related procedure codes, 7. Frequency of therapeutic encounters, 8. Duration of therapy, 9. Precautions, if applicable, 10. Short and long term goals that are specific, measurable, and age appropriate, 11. Plan for the home program, 12. Discharge plan, and 13. Therapist’s signature, name and title, and date. 1. Medicaid requires the POC to cover a period of treatment up to six (6) months. The projected period of treatment must be indicated on the initial POC and must be updated with each subsequent revised POC. Medicaid does not cover a POC for a projected period of treatment beyond six (6) months. 1. Medicaid requires a revised POC in the following situations: 1. The projected period of treatment is complete and additional services are required, 2. A significant change in the beneficiary’s condition and the proposed treatment plan requires that a therapy provider propose a revised POC to the prescribing provider, or the prescribing provider requests a revision to the POC. In either case, the therapy provider must submit a revised POC to the UM/QIO for certification prior to rendering services, and 3. Information/documentation submitted to the UM/QIO indicates the POC needs further review/revision by the therapist/prescribing provider at intervals different from the proposed treatment dates. The therapy provider must submit a revised POC to the UM/QIO for authorization/certification prior to rendering services, 2. All therapy plans of care, initial and revised, must be authenticated, with signature and date, by the prescribing provider. The prescribing provider must sign the POC before initiation of treatment or within thirty (30) calendar days of the verbal order approving the treatment plan. This applies to both initial and revised plans of care. 3. Medicaid accepts the signature on the revised plan of care as a new order. 4. The prescribing provider may make changes to the plan established by the therapist, but the therapist cannot unilaterally alter the plan of care established by the prescribing provider. 5. The servicing provider, the licensed therapist, is responsible for providing a copy of the initial plan of care and all revisions to the prescribing provider. 6. Medicaid does not cover therapy services when documentation supports that the beneficiary has not reached therapy goals and is unable to participate and/or benefit from skilled intervention, refuses to participate, or is otherwise noncompliant with the therapy regimen. Noncompliance is defined as failure to follow therapeutic recommendations which may include any or all of the following: 1. Failure to attend scheduled therapy sessions, 2. Failure to perform home exercise program as instructed by the therapist, 3. Failure to fully participate in therapy sessions, 4. Failure of the parent/caregiver to attend therapy sessions with beneficiary who is incapable of carrying out the home program without assistance, and 5. Failure to properly use special equipment or adaptive devices. Failure of parent/caregiver/beneficiary to otherwise comply with therapy regimen as documented in the medical record. 7. Medicaid requires a mandatory face-to-face visit with the beneficiary by the prescribing provider at least every six (6) months and, requires the encounter is documented.