Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 14 - OCCUPATIONAL AND PHYSICAL THERAPY SERVICES
Section 471-14-004 - SERVICE REQUIREMENTS
Universal Citation: 471 NE Admin Rules and Regs ch 14 ยง 004
Current through March 20, 2024
004.01 GENERAL SERVICE REQUIREMENTS.
004.01(A)
MEDICAL
NECESSITY. The Department incorporates the medical necessity
requirements outlined in 471 NAC 1 as if fully rewritten herein. Services and
supplies that do not meet the requirements in 471 NAC 1 are not
covered.
004.01(B)
SERVICE CRITERIA. The Department covers occupational
therapy (OT) or physical therapy (PT) services when the following criteria are
met. The service must be:
(i) An
evaluation;
(ii) Restorative
therapy with a medically appropriate expectation that the client's condition
will improve significantly within a reasonable period of time; or
(iii) For physical therapy (PT) services
only, recommended in a Department-approved Individual Program Plan (IPP), and
the client is receiving services through one of the following waiver programs:
(1) Developmental Disabilities (DD) Adult
Comprehensive Services Waiver;
(2)
Developmental Disabilities (DD) Adult Residential Services Waiver;
(3) Developmental Disabilities (DD) Adult Day
Services Waiver;
(4) Community
Supports Waiver; or
(5) Home and
Community Based Services Waiver for Children with Developmental Disabilities
and their Families.
004.01(C)
SERVICES FOR
INDIVIDUALS AGE 21 AND OLDER. For clients age 21 and older, the
Department covers a combined total of 60 therapy sessions per fiscal year (July
1 through June 30). The combined total of 60 therapy sessions per fiscal year
includes all occupational therapy (OT), physical therapy (PT), and speech
therapy sessions provided to the client.
004.02 COVERED SERVICES. The Department covers occupational therapy (OT) or physical therapy (PT) services when the following criteria are met:
(1) The services are ordered by a licensed
physician or nurse practitioner;
(2) The services are medically necessary;
and
(3) The services are such that
only a licensed occupational therapist (OT) or physical therapist (PT) can
safely and effectively perform the service.
004.02(A)
MAINTENANCE
PROGRAM. The occupational therapist (OT) or physical therapist
(PT) must:
(i) Evaluate the client's
needs;
(ii) Design a maintenance
program; and
(iii) Instruct the
client, family members, or nursing facility staff in carrying out the
program.
004.02(B)
ORTHOTIC APPLIANCES AND DEVICES. The Department covers
orthotic appliances and devices when medically necessary for the client's
condition, and when the orthotic appliance or device is used during the therapy
session.
004.02(C)
SUPPLIES. The Department covers supplies used during
the course of treatment that require application by the occupational therapist
(OT) or physical therapist (PT) when they are not incidental to the
procedure.
004.03 NON-COVERED OCCUPATIONAL THERAPY OR PHYSICAL THERAPY SERVICES. The Department does not cover occupational therapy (OT) or physical therapy (PT) services in the following situations:
(A) Maintenance therapy
provided by an occupational therapist (OT) or physical therapist
(PT);
(B) Therapy for work
hardening, or vocational and prevocational assessment and training;
(C) Therapy for functional capacity
evaluations, educational testing, drivers training, training in non-essential
self-help or recreational activities, training related to a learning disability
or attention disorder, visual perception training, or treatment of
psychological conditions;
(D)
In-service training for nursing facility staff which is not client
specific;
(E) Rental of equipment;
or
(F) Take home
supplies.
Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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