Therapy prior authorization and habilitation coverage changes
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Governance of prior authorization thresholds, coding, and treatment plan requirements for physical, occupational, and speech-language pathology services under Alaska Medicaid; affects providers furnishing therapy services to Alaska Medicaid members.
Prior authorization required for therapy services for members 21 and older once specified fiscal-year unit thresholds are met.
Habilitation services will be covered for members of any age effective March 3, 2023.
Treatment plan oversight expanded to include Physicians, PAs, and APRNs; prescribing-provider requirement removed.
Treatment plan review interval for physical and speech therapy for members 21+ increased from every 4 weeks to every 6 weeks.
Coverage Criteria and Habilitation
Prior Authorization Trigger Criteria
Prior authorization is required when ALL of the following are met
PA trigger
- Member is age 21 years or older.
Fiscal-year utilization meets or exceeds thresholds
- PT and OT evaluations combined: >= 2 units per fiscal year.
- PT and OT modalities and therapeutic procedures combined: >= 30 units per fiscal year.
- Speech-language pathology (SLP) evaluations: >= 8 units per fiscal year.
- Speech-language pathology (SLP) therapy: >= 15 units per fiscal year.
Utilization resets to zero on July 1 each year; PT and OT units are calculated together while SLP units are calculated separately; prior authorization requirement effective start of fiscal year 7/1/2023.
Habilitation services are covered for Alaska Medicaid members of any age effective 03/03/2023. This coverage applies regardless of member age and became effective on the date noted.
Codes and Thresholds Subject to Prior Authorization
| 92526 | Oral Function Therapy |
| 97010 | Hot Or Cold Packs Therapy |
| 97012 | Mechanical Traction Therapy |
| 97014 | Electric Stimulation Therapy |
| 97016 | Vasopneumatic Device Therapy |
| 97018 | Paraffin Bath Therapy |
| 97022 | Whirlpool Therapy |
| 97024 | Diathermy e.g. Microwave |
| 97026 | Infrared Therapy |
| 97028 | Ultraviolet Therapy |
| 92521 | Evaluation of Speech Fluency |
| 92522 | Evaluation of Speech Production |
| 92523 | Evaluation of Sound Language Comp.. |
| 92524 | Behavioral Qualitative Analysis Voice |
| 92507 | Speech/Hearing Therapy |
| 92508 | Speech/Hearing Therapy (Group) |
| 92526 | Oral Function Therapy |
| 92606 | Therapeutic Service for Non-Speech Device |
| 92609 | Therapeutic Service for Speech Device |
| 92630 | Auditory Rehabilitation Pre-Lingual Hearing Loss |
Provider Actions, Prior Authorization, and Treatment Plan Requirements
Prior authorization required when fiscal-year unit thresholds are met (members 21+)
Prior authorization is required for therapy services for members aged 21 years and older when the fiscal-year reimbursed unit thresholds are met or exceeded. Thresholds: 2 units of PT/OT evaluations (combined); 30 units of PT/OT modalities and therapeutic procedures (combined); 8 units of SLP evaluations; 15 units of SLP therapy. Utilization is counted per fiscal year (July 1–June 30) and resets July 1 each year.
- Applies only to members aged 21 years and older
- PT and OT units are calculated together; SLP units are calculated separately
- Utilization period: fiscal year (July 1–June 30); resets July 1
Operational notes and timing for PA implementation
Key operational points: utilization counts reset July 1 each year; the PA requirement takes effect at the start of the next fiscal year (7/1/2023); guidance for requesting service authorization and the list of procedure codes subject to PA will be announced prior to 7/1/2023.
- Member utilization restarts at zero units on July 1 each year
- PA requirement effective start of next fiscal year: 7/1/2023
- Procedure codes subject to PA and guidance for requesting authorization will be published before 7/1/2023
Treatment plan review, authorized signers, and interval (members 21+)
Treatment plans must be reviewed and signed by an authorized healthcare provider: a Physician, Physician Assistant (PA), or Advanced Practice Registered Nurse (APRN). For members 21 and older, physical and speech-language pathology treatment plans must be updated and reviewed every 6 weeks.
- Authorized signers: Physician, PA, or APRN (prescribing-provider requirement removed)
- Review interval for members 21+: physical and speech therapy every 6 weeks (changed from every 4 weeks)
Obtain PA before services once fiscal-year thresholds are met — denial risk if not obtained
When a member aged 21 or older has reached the specified fiscal-year unit thresholds, providers must obtain prior authorization before furnishing additional therapy services; failure to obtain PA when thresholds are met risks denial of services.
- Must secure PA prior to providing further services once fiscal-year thresholds are met
- Risk: claims for services provided without required PA may be denied
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