Therapy benefit coverage (OT, PT, Speech)
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Defines inpatient and outpatient coverage rules and visit limits for occupational, physical, and speech therapy for Arizona Complete Health members, including ALTCS members and acute benefits.
No material clinical or coverage changes in this revision.
Coverage Criteria
Outpatient OT/PT - Covered with limits
Covered when ALL of the following are met:
Applies to OT and PT outpatient acute benefits
Applies to OT and PT outpatient acute benefits
ALTCS outpatient - Covered when medically necessary
ALTCS member coverage statements:
No explicit visit limit stated for ALTCS outpatient in the table
Inpatient therapy - Covered when medically necessary
Inpatient services:
Applies to occupational therapy inpatient benefits
Applies to physical therapy inpatient benefits
Applies to speech therapy inpatient benefits
Speech therapy provided as an outpatient, acute benefit is not a covered benefit. Requests for outpatient acute speech therapy are therefore subject to denial and should not be submitted as a covered outpatient acute benefit.
Coding and Visit Limits
Provider Actions and Requirements
Outpatient OT/PT visit limits (15 visits/benefit year)
Outpatient occupational and physical therapy outpatient benefits are limited to 15 visits per benefit year (benefit year = 10/01–9/30) for either: (1) restoring a previously held skill or function lost due to injury or disease and maintaining that function once restored, or (2) attaining/acquiring a skill or function never learned and maintaining it once acquired. Verify prior authorization requirements with the payer when requesting services that approach or exceed these limits or for outpatient ALTCS services.
- Limit = 15 visits per benefit year (10/01–9/30).
- Applies to OT and PT outpatient acute benefits; outpatient ALTCS may have separate rules — verify with payer.
- Prior authorization may be required when requesting services that approach or exceed these limits.
Verify ALTCS and payer-specific authorization steps
For outpatient ALTCS benefits and other cases not explicitly limited in the table, follow the payer’s medical necessity and authorization procedures. Confirm any additional operational prior authorization steps with Arizona Complete Health.
Document medical necessity to support coverage
Coverage for inpatient and outpatient OT, PT, and ALTCS speech services is contingent on medical necessity; providers must document medical necessity in the medical record to support coverage decisions.
- Document clinical rationale showing need for therapy, goals, expected functional improvement, and reason for number of visits requested.
- Ensure documentation distinguishes whether services are for restoration of lost function or acquisition of new skills, as visit limits apply for outpatient acute OT/PT.
Denial risk for exceeding visit limits
Requests that exceed the outpatient OT/PT visit limit (15 visits per benefit year, 10/01–9/30) may be denied as beyond the covered benefit. When planning care, obtain prior authorization for services that approach or exceed the limit to avoid denial.
- Denial risk applies to outpatient OT/PT acute benefits when requests exceed 15 visits per benefit year.
- Obtain prior authorization or provide clear medical necessity justification for additional visits.
Outpatient acute speech therapy is not covered
Outpatient, acute speech therapy is explicitly listed as Not a covered benefit and requests for outpatient acute speech therapy are subject to denial.
- Speech therapy: Outpatient, acute benefit = Not a covered benefit.
Background
Occupational and physical therapies are rehabilitation services intended to restore, teach, or maintain skills and functions that have been lost or never acquired due to injury, disease, or developmental conditions. For inpatient acute and inpatient ALTCS settings, OT, PT, and speech therapy are covered when medically necessary.
For outpatient acute settings, OT and PT are covered with limits: each is allowed up to 15 visits per benefit year (10/01 - 9/30) when used either to restore a previously held skill or function lost because of injury or disease and to maintain it once restored, or to attain a skill or function never learned and maintain it once acquired. ALTCS outpatient OT, PT, and speech services are covered when medically necessary.
Definitions
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