Medicaid covers therapy services that are medically
necessary, as certified by the prescribing provider.
A. The prescribing provider must complete a
Certificate of Medical Necessity for Initial Referral/Orders and submit it to
the therapist prior to the therapy evaluation. Medicaid defines prescribing
provider as a state-licensed physician, nurse practitioner, or physician
assistant who refers the beneficiary for therapy services.
B. Therapy services must be furnished
according to a written plan of care (POC).
1.
The POC must be approved by the prescribing provider before treatment is begun.
a) An approved POC does not mean that the
prescribing provider has signed the POC prior to implementation, but only has
agreed to it.
b) Medicaid covers
for the review to be done in person, by telephone, or facsimile.
2. The POC must be developed by a
therapist in the discipline.
3. A
separate POC is required for each type of therapy ordered by the prescribing
provider.
4. Medicaid requires that
the POC must, at a minimum, include the following:
a) Beneficiary demographic
information,
b) Name of the
prescribing provider,
c) Dates of
service,
d)
Diagnosis/symptomatology/conditions and related diagnosis codes,
e) Specific diagnostic and treatment
procedures/modalities and related procedure codes,
f) Reason for referral,
g) Frequency of therapeutic
encounters,
h) Duration of
therapy,
i) Precautions, if
applicable,
j) Short and long term
goals that are specific, measurable, and age appropriate,
k) Plan for the home program,
l) Discharge plan, and
m) Therapist's signature including name,
title, and the date of the therapy session.
5. Medicaid requires the POC to be developed
to cover a period of treatment not to exceed six (6) months.
a) The projected period of treatment must be
indicated on the initial POC and must be updated with each subsequent revised
POC.
b) A POC for a projected
period of treatment beyond six (6) months is not covered by Medicaid.
6. Medicaid requires a revised POC
in the following situations:
a) The projected
period of treatment is complete and additional services are required,
b) A significant change in the beneficiary's
condition and the proposed treatment plan requires that:
1) A therapy provider propose a revised POC
to the prescribing provider, or
2)
The prescribing provider requests a revision to the POC. Information and
documentation submitted to the UM/QIO indicates that the POC needs further
review/revision by the therapist/prescribing provider at intervals different
from the proposed treatment dates.
7. All therapy plans of care, both initial
and revised, must be authenticated by the prescribing provider's signature and
date signed. 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. Medicaid accepts the signature on the revised POC as a new
order.
8. The prescribing provider
may make changes to the POC established by the therapist, but the therapist
cannot unilaterally alter the POC established by the prescribing
provider.
C. Medicaid
requires the prescribing provider to participate in the delivery of care by
communicating with the treating therapist and by assessing the effectiveness of
the prescribed care. The prescribing provider must have a face-to-face visit
with the beneficiary at least everysix (6) months with the encounter
documented.
42
C.F.R. §
410.61; Miss. Code Ann.
§§
43-13-117,
43-13-121.
