RetiredCareSourcePolicy MM-1188

Rehabilitative Services for Persons with Physical Disabilities (RSPD)

Defines clinical eligibility, required facility staffing, plan-of-care, coverage and exclusions for Medicaid-eligible beneficiaries receiving residential rehabilitative services in Arkansas RSPD settings.

Policy Summary

PayerCareSource

PolicyRehabilitative Services for Persons with Physical Disabilities (RSPD)

Policy CodePolicy MM-1188

Change TypeClarificationAddition

Effective DateJan 1, 2022

Next Review Date

Key ActionIf a patient should not be discharged by day five, contact CareSource to request an extension and submit the principal diagnosis, days requested, and supporting medical information.

SourceLink

POLICY UPDATE CHANGES

Clarified Section D. II.

Added Medical Necessity Determinations to Section G.

30 daysphysician exam required within prior

3 monthsprescription/plan renewal

4 daysimplement plan of care by

30 daysplan review interval

7 daysallowed absentee return window

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Coverage Criteria & Exclusions

Coverage Criteria for RSPD Admission

Covered when ALL of the following are met

Eligibility and clinical criteria: Member is Medicaid-eligible; services are prescribed by a licensed physician and deemed medically necessary by the Quality Improvement Organization (QIO); diagnosis is post-acute traumatic or acquired brain injury or specified neurological conditions (examples include viral encephalitis, meningitis, aneurysms, stroke/cerebrovascular accident, post-operative tumors, anoxia/hypoxia, toxic encephalopathies, refractory seizure disorders, congenital neurological brain disorders, head injuries causing loss of consciousness with neurological deficits, or congenital spinal cord disorders).

Plan of care and documentation: An individualized, supervised plan of care developed and written by the facility-based interdisciplinary team in consultation with the member (and parent/legal guardian when applicable) is present in the member's record; the plan documents diagnostic evaluation, diagnosis(es), functional level, treatment objectives, prescribed integrated therapies/social services/activities, and the signature of a licensed physician verifying continued medical necessity.

Plan of care must be implemented no later than 4 days after admission and before Medicaid payments are authorized; plan revisions must be signed and dated by a licensed physician.

Clinical review and renewal: The physician has examined the member within thirty (30) days preceding admission and the prescription or plan of care is renewed every three (3) months for continued coverage; periodic plan of care review occurs at least every 30 days.

Facility and service requirements: Services are provided in an enrolled place of service (e.g., residential rehabilitation center or extended rehabilitative hospital) and the facility employs or contracts required interdisciplinary staff (including but not limited to occupational therapy, physical therapy, nursing, neuropsychology/physician).

Authorization for extended stay: If RSPD medical staff determine the member should not be discharged by the fifth day of residential stay, the provider must contact CareSource to request an extension and submit principal diagnosis, number of days requested, and all available medical information supporting the continued residential stay.

Length-of-stay determinations are made by CareSource.

The following services are excluded from payment under the RSPD program and may not be billed separately when included in the RSPD global coverage: beauty or barber shop services; clothing and personal allowances; costs for visitors, including meals and guest trays; dietary or nutritional consultation or plan; durable medical equipment; discharge plan; educational services (including evaluations); habilitation; leave days (including leave for therapeutic or acute care); inpatient or outpatient hospital services; occupational therapy tools (e.g., leather-working tools, scissors, construction paper); private duty nursing services; prosthetics; recreational services; room and board costs; RSPD services provided in a residential rehabilitation center to Medicaid patients age 21 and older; and any services found not to be medically necessary, reasonable or necessary for the treatment of an illness or injury.

CareSource will not cover services that are found not to be medically necessary, reasonable or necessary for the treatment of an illness or injury.

Plan of Care Timelines & Coding Notes

Plan of Care timelines

Implement plan of careSupervised, individualized plan of care must be implemented no later than 4 days after admission and before Medicaid payments are authorized.

Physician exam prior to admissionPhysician must have examined the member within 30 days preceding admission.

Renewal frequencyPrescription or plan of care must be renewed every 3 months.

Periodic review intervalPlan of care must be reviewed by the facility-based interdisciplinary team every 30 days with detailed documentation entered in the member's record.

Provider Responsibilities & Documentation

Prior Authorization

Extension Request for Continued Residential Stay

When the RSPD provider's neuropsychologist and/or physician determines that a patient age 1 year or older should not be discharged by the fifth day of residential stay due to the need for continued services, an RSPD medical staff member must contact CareSource and request an extension of the RSPD admission.

Required information to submit with the extension request:
• Principal diagnosis and other diagnoses influencing this stay
• The number of days being requested for continued residential stay
• All available medical information justifying or supporting necessity for continued stay

Documentation Required

Clinical Review and Renewal

CareSource considers RSPD services medically necessary when clinical criteria are met. For continued stays, the physician must have examined the member within 30 days prior to admission/continuation and the prescription or individualized plan of care must be renewed every three (3) months.

Policy Background

RSPD provides inpatient residential rehabilitative services for Medicaid-eligible individuals with post-acute traumatic or acquired brain injury and certain neurological conditions. Services include restorative therapies (physical, occupational, speech, cognitive), behavioral rehabilitation, counseling and assessment to prepare individuals for improved function and potential transition to less intensive care. A facility-based interdisciplinary team must develop a written plan of care that includes feasible rehabilitation goals, a projected schedule for service delivery with frequency and duration, orders for medications/diets/treatments, identification of personnel who will furnish services, and discharge and continuing care plans. The plan of care must be implemented promptly and reviewed every 30 days to assess appropriateness of services, patient progress, and the ongoing need for participation in the RSPD program.

Key Definitions

Restorative Therapies

DefinitionTherapies provided in an individual or group setting, including physical, occupational, speech and cognitive therapy.

SettingsIncluded as part of the RSPD global service covering rehabilitative, psychological and/or social services required by the admitting facility.

ExamplesMay include individual and group sessions, life skills training and restorative activities tied to the plan of care.

Plan of Care

DefinitionAn individualized plan designed to improve the member's condition to the extent that RSPD services are no longer necessary; must be developed and written by the facility-based interdisciplinary team and include diagnosis, functional level, treatment objectives, prescribed integrated therapies, personnel, discharge plans and physician signature.

Implementation timing

Policy Summary

PayerCareSource

PolicyRehabilitative Services for Persons with Physical Disabilities (RSPD)

Policy CodePolicy MM-1188

Change TypeClarificationAddition

Effective DateJan 1, 2022

Next Review Date

Key ActionIf a patient should not be discharged by day five, contact CareSource to request an extension and submit the principal diagnosis, days requested, and supporting medical information.

SourceLink

On This Page

Physician examination within 30 days preceding admission/continuation
Prescription or plan of care renewal every 3 months

Documentation Required

Required Plan of Care Documentation

A physician-signed and dated prescription or individualized plan of care must be included in the member's records. The plan of care must be developed by the facility-based interdisciplinary team, implemented no later than four (4) days after admission, reviewed every thirty (30) days, and include: diagnosis, diagnostic evaluation, description of functional level, treatment objectives, prescribed therapies and schedule, orders for medications/treatments, personnel types furnishing services, discharge plans, and plans for continuing care. Revisions must be signed and dated by a licensed physician who verifies continued medical necessity.

Physician signature and date required on prescription or plan of care
Plan implemented ≤ 4 days after admission
Plan of care reviews every 30 days with documentation in member record
Plan of care must document: diagnosis(es), symptoms, functional level, treatment objectives, prescribed integrated therapies, expected frequency and duration, medication/treatment orders, personnel types, discharge and continuing care plans

Denial Risk

Absent Days Noncoverage

CareSource will not cover days a member is absent from the facility, regardless of reason. The RSPD provider must document when the member left, reason if known, destination, and expected return date when applicable. The provider must either formally discharge the member or allow up to seven (7) days for return; if the member returns within seven days, conduct a plan of care review within three (3) days of return and modify the plan as needed. If the member does not return within seven days, the provider must formally discharge the member; readmission requires a new admission following normal procedures.

Absent days are non‑billable to CareSource
If member absent ≤ 7 days and returns: plan of care review within 3 days of return
If absent > 7 days: formal discharge required; readmission follows normal admission procedures
Document leave: time left, reason (if known), destination, expected return date

Must be implemented no later than 4 days after admission and before Medicaid payments are authorized.

Documentation requirementsPlan of care must be signed and dated by a licensed physician and always included in the member's records.

Review and revisionsRevisions must be made by the interdisciplinary team, signed and dated by a licensed physician who verifies continued medical necessity; periodic reviews every 30 days with documentation in the member's record.

Medically Necessary

Core definitionA service is medically necessary if it is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent worsening of conditions that endanger life, cause suffering, illness or injury, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction.

Conservatism and costMedically necessary when there is no other equally effective, more conservative, or less costly course of treatment available or suitable for the member.

ScopeApplies to services provided as part of RSPD and determines coverage eligibility when clinical criteria are met.