Current through Register Vol. 49, No. 9, September, 2024
214.310
Accepted Tests for
Occupational Therapy
Tests used must be norm referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test that is not listed below, the provider
must include documentation in the evaluation to support the reliability and
validity of the test. This additional information will be used as reference
information if the chart is selected by Medicaid for review. An explanation of
why a test from the approved list could not be used to evaluate the child
should be included. The Mental Measurement Yearbook (MMY) is
the standard reference to determine the reliability and validity of the test(s)
administered in the evaluation. Providers should refer to the MMY for
additional information regarding specific tests. The following definitions of
terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine
deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits
and support other results. Supplemental tests may not supplant standard
tests.
* CLINICAL OBSERVATIONS: Clinical observations have a
supplemental role in the evaluation and should always be included. Detail,
precision and comprehensiveness of clinical observations are especially
important when standard scores do not qualify the patient for therapy and the
clinical notes constitute the primary justification of medical
necessity.
A. Fine Motor Skills -
Standard
1. Peabody Developmental Motor
Scales (PDMS, PDMS2)
2. Toddler and
Infant Motor Evaluation (TIME)
3.
Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance
(TIMP)
B. Fine Motor
Skills - Supplemental
1. Early Learning
Accomplishment Profile (ELAP)
2.
Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning,
Infant/Preschool (MSEL)
4. Miller
Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile
(HELP)
7. Battelle Developmental
Inventory (BDI)
8. Developmental
Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory
(BDI)
C. Visual
Motor-Standard
1. Developmental Test of Visual
Motor Integration (VMI)
2. Test of
Visual Motor Integration (TVMI)
3.
Test of Visual Motor Skills
4. Test
of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual
Test
2. Motor Free Visual
Perceptual Test - R (MVPT)
3.
Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper
level) (TVPS)
E.
Handwriting - Standard
1. Evaluation Test of
Children's Handwriting (ETCH)
2.
Test of Handwriting Skills (THS)
3.
Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for
Infants/Toddlers
2. Sensory Profile
for Preschoolers
3. Sensory Profile
for Adolescents/Adults
4. Sensory
Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised
(Sll-R)
6. Sensory Profile School
Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance
Analysis
2. Analysis of Sensory
Behavior
3. Sensory Integration
Inventory
4. DeGangi-Berk Test of
Sensory Integration
H.
Activities of Daily Living/Vocational/Other - Standard
1. Pediatric Evaluation of Disability
Inventory (PEDI)
NOTE: The PEDI can also be used for older children whose
functional abilities fall below that expected of a VA year old
with no disabilities. In this case, the scaled score is the most appropriate
score to consider.
2. Adaptive Behavior Scale - School
(ABS)
3. Jacobs Pre-vocational
Assessment
4. Kohlman Evaluation of
Daily Living Skills
5. Milwaukee
Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure - 7 years
of age to adult (FIM)
9. Functional
Independence Measure -young version (WeeFIM) I. Activities of Daily
Living/Vocational/Other- Supplemental
1. School Function Assessment (SFA)
2. Bay Area Functional Performance
Evaluation
3. Manual Muscle
Test
4. Grip and Pinch
Strength
5. Jordan Left-Right
Reversal Test
6. Erhardy
Developmental Prehension
7. Knox
Play Scale
8. Social Skills Rating
System
9. Goodenough Harris Draw a
Person Scale
TOC not required
227.210
Accepted Tests for Occupational Therapy
Tests used must be norm referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test that is not listed below, the provider
must include documentation in the evaluation to support the reliability and
validity of the test. This additional information will be used as reference
information if the chart is selected by Medicaid for review. An explanation of
why a test from the approved list could not be used to evaluate the child must
also be included. The Mental Measurement Yearbook (MMY) is the
standard reference to determine the reliability and validity of the test(s)
administered in an evaluation. Providers should refer to the MMY for additional
information regarding specific tests. The following definitions of terms are
applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine
deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits
and support other results. Supplemental tests may not supplant standard
tests.
* CLINICAL OBSERVATIONS: Clinical observations have a
supplemental role in the evaluation and should always be included. Detail,
precision and comprehensiveness of clinical observations are especially
important when standard scores do not qualify the patient for therapy and the
clinical notes constitute the primary justifications of medical
necessity.
A. Fine Motor Skills -
Standard
1. Peabody Developmental Motor
Scales (PDMS, PDMS2)
2. Toddler and
Infant Motor Evaluation (TIME)
3.
Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance
(TIMP)
B. Fine Motor
Skills - Supplemental
1. Early Learning
Accomplishment Profile (ELAP)
2.
Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning,
Infant/Preschool (MSEL)
4. Miller
Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile
(HELP)
7. Battelle Developmental
Inventory (BDI)
8. Developmental
Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory
(BDI)
C. Visual
Motor-Standard
1. Developmental Test of Visual
Motor Integration (VMI)
2. Test of
Visual Motor Integration (TVMI)
3.
Test of Visual Motor Skills
4. Test
of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual
Test
2. Motor Free Visual
Perceptual Test - R (MVPT)
3.
Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper
level) (TVPS)
E.
Handwriting - Standard
1. Evaluation Test of
Children's Handwriting (ETCH)
2.
Test of Handwriting Skills (THS)
3.
Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for
Infants/Toddlers
2. Sensory Profile
for Preschoolers
3. Sensory Profile
for Adolescents/Adults
4. Sensory
Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised
(Sll-R)
6. Sensory Profile School
Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance
Analysis
2. Analysis of Sensory
Behavior
3. Sensory Integration
Inventory
4. DeGangi-Berk Test of
Sensory Integration
H.
Activities of Daily Living/Vocational/Other - Standard
1. Pediatric Evaluation of Disability
Inventory (PEDI)
NOTE: The PEDI can also be used for older children whose
functional abilities fall below that expected of a
71/2 year old with no
disabilities. If this is the case, the scaled score is the most appropriate
score to consider.
2.
Adaptive Behavior Scale - School (ABS)
3. Jacobs Pre-vocational Assessment
4. Kohlman Evaluation of Daily Living
Skills
5. Milwaukee Evaluation of
Daily Living Skills
6. Cognitive
Performance Test
7. Purdue
Pegboard
8. Functional Independence
Measure (FIM) 7 years of age to adult
9. Functional Independence Measure -young
version (WeeFIM)
I.Activities of Daily Living/Vocational/Other- Supplemental
1. School Function Assessment (SFA)
2. Bay Area Functional Performance
Evaluation
3. Manual Muscle
Test
4. Grip and Pinch
Strength
5. Jordan Left-Right
Reversal Test
6. Erhardy
Developmental Prehension
7. Knox
Play Scale
8. Social Skills Rating
System
9. Goodenough Harris Draw a
Person Scale
TOC required
216.120
Accepted Tests for Occupational Therapy
Tests must be norm referenced, standardized, age appropriate
and specific to the therapy provided. The following list of tests is not
all-inclusive. When using a test that is not listed below, the provider must
include documentation in the evaluation to support the reliability and validity
of the test. This additional information will be used as reference information
if the chart is selected by Medicaid for review. An explanation of why a test
from the approved list could not be used to evaluate the patient must also be
included. The Mental Measurement Yearbook (MMY) is the
standard reference for determining the reliability and validity of tests
administered in an evaluation. Providers should refer to the MMY for additional
information regarding specific tests. The following definitions of terms are
applied to the lists of accepted tests:
* Standard:Evaluations that are used to determine
deficits.
* Supplemental:Evaluations that are used to
identify deficits and support other results. Supplemental tests may not
supplant standard tests.
* Clinical observations:Clinical observations have
a supplemental role in the evaluation and should always be included. Detail,
precision and comprehensiveness of clinical observations are especially
important when standard scores do not qualify the patient for therapy and the
clinical notes constitute the primary justification of medical
necessity.
A. Fine Motor Skills -
Standard
1. Peabody Developmental Motor
Scales (PDMS, PDMS2)
2. Toddler and
Infant Motor Evaluation (TIME)
3.
Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance
(TIMP)
B. Fine Motor
Skills - Supplemental
1. Early Learning
Accomplishment Profile (ELAP)
2.
Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning,
Infant/Preschool (MSEL)
4. Miller
Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile
(HELP)
7. Battelle Developmental
Inventory (BDI)
8. Developmental
Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory
(BDI)
C. Visual
Motor-Standard
1. Developmental Test of Visual
Motor Integration (VMI)
2. Test of
Visual Motor Integration (TVMI)
3.
Test of Visual Motor Skills
4. Test
of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual
Test
2. Motor Free Visual
Perceptual Test - R (MVPT)
3.
Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper
level) (TVPS)
E.
Handwriting - Standard
1. Evaluation Test of
Children's Handwriting (ETCH)
2.
Test of Handwriting Skills (THS)
3.
Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for
Infants/Toddlers
2. Sensory Profile
for Preschoolers
3. Sensory Profile
for Adolescents/Adults
4. Sensory
Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised
(Sll-R)
6. Sensory Profile School
Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance
Analysis
2. Analysis of Sensory
Behavior
3. Sensory Integration
Inventory
4. DeGangi-Berk Test of
Sensory Integration
H.
Activities of Daily Living/Vocational/Other- Standard
1. Pediatric Evaluation of Disability
Inventory (PEDI)
NOTE:The PEDI can also be used for older children
whose functional abilities fall below that expected of a IVi
year old with no disabilities. In this case, the scaled score is the
most appropriate score to consider.
2. Adaptive Behavior Scale - School
(ABS)
3. Jacobs Pre-vocational
Assessment
4. Kohlman Evaluation of
Daily Living Skills
5. Milwaukee
Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure - 7 years
of age to adult (FIM)
9. Functional
Independence Measure -young version (WeeFIM)
I. Activities of Daily
Living/Vocational/Other - Supplemental
1.
School Function Assessment (SFA)
2.
Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale
TOC not required
218.120
Accepted Tests for Occupational Therapy
Tests must be norm referenced, standardized, age appropriate
and specific to the therapy provided. The following list of tests is not
all-inclusive. When using a test that is not listed below, the provider must
include documentation in the evaluation to support the reliability and validity
of the test. This additional information will be used as reference information
if the chart is selected by Medicaid for review. An explanation of why a test
from the approved list could not be used to evaluate the patient must also be
included. The Mental Measurement Yearbook (MMY) is the
standard reference for determining the reliability and validity of tests
administered in an evaluation. Providers should refer to the MMY for additional
information regarding specific tests. The following definitions of terms are
applied to the lists of accepted tests:
* Standard:Evaluations that are used to determine
deficits.
* Supplemental:Evaluations that are used to
identify deficits and support other results. Supplemental tests may not
supplant standard tests.
* Clinical observations:Clinical observations have
a supplemental role in the evaluation and should always be included. Detail,
precision and comprehensiveness of clinical observations are especially
important when standard scores do not qualify the patient for therapy and the
clinical notes constitute the primary justification of medical
necessity.
A. Fine Motor Skills -
Standard
1. Peabody Developmental Motor
Scales (PDMS, PDMS2)
2. Toddler and
Infant Motor Evaluation (TIME)
3.
Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance
(TIMP)
B. Fine Motor
Skills - Supplemental
1. Early Learning
Accomplishment Profile (ELAP)
2.
Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning,
Infant/Preschool (MSEL)
4. Miller
Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile
(HELP)
7. Battelle Developmental
Inventory (BDI)
8. Developmental
Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory
(BDI)
C. Visual
Motor-Standard
1. Developmental Test of Visual
Motor Integration (VMI)
2. Test of
Visual Motor Integration (TVMI)
3.
Test of Visual Motor Skills
4. Test
of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual
Test
2. Motor Free Visual
Perceptual Test - R (MVPT)
3.
Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper
level) (TVPS)
E.
Handwriting - Standard
1. Evaluation Test of
Children's Handwriting (ETCH)
2.
Test of Handwriting Skills (THS)
3.
Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for
Infants/Toddlers
2. Sensory Profile
for Preschoolers
3. Sensory Profile
for Adolescents/Adults
4. Sensory
Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised
(Sll-R)
6. Sensory Profile School
Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance
Analysis
2. Analysis of Sensory
Behavior
3. Sensory Integration
Inventory
4. DeGangi-Berk Test of
Sensory Integration
H.
Activities of Daily Living/Vocational/Other- Standard
1. Pediatric Evaluation of Disability
Inventory (PEDI)
NOTE:The PEDI can also be used for older children
whose functional abilities fall below that expected of a TA
year old with no disabilities. In this case, the scaled score is the
most appropriate score to consider.
2. Adaptive Behavior Scale - School
(ABS)
3. Jacobs Pre-vocational
Assessment
4. Kohlman Evaluation of
Daily Living Skills
5. Milwaukee
Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure - 7 years
of age to adult (FIM)
9. Functional
Independence Measure -young version (WeeFIM)
I. Activities of Daily
Living/Vocational/Other - Supplemental
1.
School Function Assessment (SFA)
2.
Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale
TOC not required
220.110
Accepted Tests for Occupational Therapy
Tests used must be norm referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test not listed below, the provider must
include documentation in the evaluation to support the reliability and validity
of the test. This additional information will be used as reference information
if the chart is selected by Medicaid for review. An explanation of why a test
from the approved list could not be used to evaluate the child must also be
included. The Mental Measurement Yearbook (MMY) is the
standard reference to determine the reliability and validity of the test(s)
administered in an evaluation. Providers should refer to the MMY for additional
information regarding specific tests. The following definitions of terms are
applied to the lists of accepted tests:
* STANDARD:Evaluations that are used to determine
deficits.
* SUPPLEMENTAL:Evaluations that are used to
identify deficits and support other results. Supplemental tests may not
supplant standard tests.
* CLINICAL OBSERVATIONS:Clinical observations have
a supplemental role in the evaluation and should always be included. Detail,
precision and comprehensiveness of clinical observations are especially
important when standard scores do not qualify the patient for therapy and the
clinical notes constitute the primary justification of medical
necessity.
A. Fine Motor Skills -
Standard
1. Peabody Developmental Motor
Scales (PDMS, PDMS2)
2. Toddler and
Infant Motor Evaluation (TIME)
3.
Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance
(TIMP)
B. Fine Motor
Skills - Supplemental
1. Early Learning
Accomplishment Profile (ELAP)
2.
Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning,
Infant/Preschool (MSEL)
4. Miller
Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile
(HELP)
7. Battelle Developmental
Inventory (BDI)
8. Developmental
Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory
(BDI)
C. Visual
Motor-Standard
1. Developmental Test of Visual
Motor Integration (VMI)
2. Test of
Visual Motor Integration (TVMI)
3.
Test of Visual Motor Skills
4. Test
of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual
Test
2. Motor Free Visual
Perceptual Test - R (MVPT)
3.
Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper
level) (TVPS)
E.
Handwriting - Standard
1. Evaluation Test of
Children's Handwriting (ETCH)
2.
Test of Handwriting Skills (THS)
3.
Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for
Infants/Toddlers
2. Sensory Profile
for Preschoolers
3. Sensory Profile
for Adolescents/Adults
4. Sensory
Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised
(Sll-R)
6. Sensory Profile School
Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance
Analysis
2. Analysis of Sensory
Behavior
3. Sensory Integration
Inventory
4. DeGangi-Berk Test of
Sensory Integration
H.
Activities of Daily Living/Vocational/Other - Standard
1. Pediatric Evaluation of Disability
Inventory (PEDI)
NOTE: The PEDI can also be used for older children whose
functional abilities fall below that expected of a
71/2 year old with no
disabilities. In this case, the scaled score is the most appropriate score to
consider.
2. Adaptive
Behavior Scale - School (ABS)
3.
Jacobs Pre-vocational Assessment
4.
Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living
Skills
6. Cognitive Performance
Test
7. Purdue Pegboard
8. Functional Independence Measure (FIM) 7
years of age to adult
9. Functional
Independence Measure -young version (WeeFIM)
I. Activities of Daily
Living/Vocational/Other- Supplemental
1.
School Function Assessment (SFA)
2.
Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale
TOC not required
220.200
Procedures for Extension of Benefits of CHMS
Diagnosis/Evaluation
A. Extension of benefits for medically
necessary CHMS diagnosis and evaluation procedures may be requested. To request
extension of benefits, submit a completed form DMS-699-A CHMS Benefit Extension
for Diagnosis/Evaluation Procedures and additional medical records including
the most recent multidisciplinary evaluation to substantiate medical necessity
to AFMC. View or print CHMS Benefit Extension for
Diagnosis/Evaluation Procedures form DMS-699-A and instructions for completion.
View or print AFMC contact information.
B. AFMC, which includes medical personnel,
will review the medical records and will notify the requesting provider of the
approval or denial of the request. AFMC will forward the approved Benefit
Extension Numbers to the provider for the procedure codes requested.
220.300
Procedures
for Extension of Benefits of CHMS
Diagnosis/Evaluation or Specified Treatment
Services
To request benefit extensions for medically necessary CHMS
diagnosis/evaluation procedure codes or specified treatment procedure
codes:
Submit a CHMS Benefit Extension form and additional medical
records including the most recent multidisciplinary evaluation to substantiate
medical necessity to AFMC. View or print DMS-699-A CHMS
Benefit Extension form and instructions for completion. View or print AFMC
contact information.
AFMC, which includes medical personnel, will review the medical
records and will notify the requesting provider of the approval or denial of
the request. AFMC will forward the approved Benefit Extension Numbers to the
provider for the procedure codes requested.
242.000
Prior Authorization Request to
Determine and Verify the Patient's
Need for Child Health Management Services
Intervention and treatment services for Medicaid beneficiaries
must be prior authorized in accordance with the following procedures.
A. When a recommendation is made for
intervention/treatment services, the CHMS Request for Prior Authorization form
DMS-102 must be completed by the CHMS clinic and submitted via mail or fax to
the Arkansas Foundation for Medical Care (AFMC). Fax transmission will be
limited to 25 pages. For those clinics wishing to utilize electronic
submission, contact AFMC and request specifics.
View or print
CHMS Request for Prior Authorization form DMS-102 and instructions for
completion. View or print AFMC contact information.
The request must include a report of the findings from
evaluations and a current plan for treatment. Review for medical necessity will
be performed on the information sent by the provider. This information must
substantiate the need for the child to receive services in a multidisciplinary
CHMS clinic.
B. The request
will be screened by the CHMS review coordinator.
1. When completed documents are received, a
review for prior authorization of requested services will be performed. If the
CHMS review coordinator cannot approve all of the procedure codes requested,
the request form and documentation will be sent to a physician advisor for his
or her determination.
2. There may
be complete approval, partial approval or complete denial of procedure codes
requested. Reconsideration may be requested within thirty (30) calendar days of
the date on the denial letter.
3.
Reconsideration review will be performed by a different physician
advisor.
C. If services
are approved, the requesting CHMS clinic will be issued an authorization
number. A preliminary length of service, procedure codes and units approved
will be designated.
D. In cases
where the patient could be served at either a CHMS clinic or a Developmental
Day Treatment Clinic (DDTCS), AFMC will notify the parents and the patient's
primary care physician (PCP) of the options for type of clinic.
E. The determination by AFMC will be pended
for a maximum of 30 days to allow the parent to choose the clinic where
services will be provided.
F. Once
the determination has been made, the CHMS clinic will be notified of the prior
authorization disposition.
G. The
prior authorization process will be completed within fifteen (15) working days
of receipt of all required documentation. Intervention/Treatment Services may
begin prior to the receipt of prior authorization only at the financial risk of
the CHMS organization.
Refer to the flow chart in Section
244.000 of this manual for the
process outlined above.
244.000
Flow Chart of Intake and Prior
Authorization Process for
Intervention/Treatment
View or print Flow Chart of Intake and Prior
Authorization Process for Intervention/Treatment.
View or print DMS-102 CHMS Request for Prior
Authorization Form and instructions for
completion.
245.110
Accepted Tests for Occupational
Therapy
Tests used must be norm-referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test that is not listed below, the provider
must include documentation in the evaluation to support the reliability and
validity of the test. This additional information will be used as reference
information if the chart is selected by Medicaid for audit review. An
explanation of why a test from the approved list could not be used to evaluate
the child must also be included. The Mental Measurement Yearbook (MMY)
is the standard reference to determine the reliability and validity of
the test(s) administered in an evaluation. Providers should refer to the MMY
for additional information regarding specific tests. The following definitions
of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine
deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits
and support other results. Supplemental tests may not supplant standard
tests.
* CLINICAL OBSERVATIONS: Clinical observations have a
supplemental role in the evaluation and should always be included. Detail,
precision and comprehensiveness of clinical observations are especially
important when standard scores do not qualify the patient for therapy and the
clinical notes constitute the primary justification of medical
necessity.
A. Fine Motor Skills -
Standard
1. Peabody Developmental Motor
Scales (PDMS, PDMS2)
2. Toddler and
Infant Motor Evaluation (TIME)
3.
Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance
(TIMP)
B. Fine Motor
Skills - Supplemental
1. Early Learning
Accomplishment Profile (ELAP)
2.
Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning,
Infant/Preschool (MSEL)
4. Miller
Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile
(HELP)
7. Battelle Developmental
Inventory (BDI)
8. Developmental
Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory
(BDI)
C. Visual
Motor-Standard
1. Developmental Test of Visual
Motor Integration (VMI)
2. Test of
Visual Motor Integration (TVMI)
3.
Test of Visual Motor Skills
4. Test
of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual
Test
2. Motor Free Visual
Perceptual Test - R (MVPT)
3.
Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper
level) (TVPS)
E.
Handwriting - Standard
1. Evaluation Test of
Children's Handwriting (ETCH)
2.
Test of Handwriting Skills (THS)
3.
Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for
Infants/Toddlers
2. Sensory Profile
for Preschoolers
3. Sensory Profile
for Adolescents/Adults
4. Sensory
Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised
(Sll-R)
6. Sensory Profile School
Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance
Analysis
2. Analysis of Sensory
Behavior
3. Sensory Integration
Inventory
4. DeGangi-Berk Test of
Sensory Integration
H.
Activities of Daily Living/Vocational/Other - Standard
1. Pediatric Evaluation of Disability
Inventory (PEDI)
NOTE: The PEDI can also be used for older children whose
functional abilities fall below that expected of a
71/2 year old with no
disabilities. In this case, the scaled score is the most appropriate score to
consider.
2. Adaptive
Behavior Scale - School (ABS)
3.
Jacobs Pre-vocational Assessment
4.
Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living
Skills
6. Cognitive Performance
Test
7. Purdue Pegboard
8. Functional Independence Measure (FIM) 7
years of age to adult
9. Functional
Independence Measure -young version (WeeFIM)
I. Activities of Daily
Living/Vocational/Other- Supplemental
1.
School Function Assessment (SFA)
2.
Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person
Scale
