Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only)
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Defines documentation, prior authorization, visit-approval criteria, and provider requirements for outpatient occupational, physical, and speech therapy for members in Florida; governs evaluation, re-evaluation, initial and continuation visit authorizations and exclusions.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Speech therapy visit frequency criteria
Speech therapy visits are approved based on standardized assessment severity banding and corresponding frequency/duration limits:
Case-by-case basis
Case-by-case basis
Case-by-case basis
Medical Necessity Criteria
Covered when services meet the policy definition of medical necessity
Inpatient services require that inpatient care cannot be furnished more economically on an outpatient basis or in a different inpatient facility (AHCA, May 2024).
Services will not be covered when they duplicate other paid services, do not meet the policy’s Medical Necessity requirements, or when the member does not meet eligibility rules. Routine activities associated with developing or updating the plan of care (POC), mileage and travel expenses, and costs to secure, install, or maintain therapy equipment are excluded. Services not listed on the fee schedule, telephone communications (except as allowed under the telemedicine policy), time spent supervising assistants or students, treatment visits on the same day as an evaluation, and multiple AAC fitting/adjustment/training visits on the same day (speech therapy only) are also not covered.
Services that are experimental or investigational, provided primarily for convenience, or in excess of the patient’s needs are excluded from coverage. Consistent with the policy’s Medical Necessity definition, services that are not supported by generally accepted professional standards or that do not meet AHCA criteria should be treated as noncovered.
Services that do not meet the policy’s Medical Necessity definition are not covered. Medical Necessity requires that care: protects life, prevents significant illness or disability, or alleviates severe pain; is individualized and consistent with the confirmed diagnosis and not in excess of patient needs; is consistent with generally accepted professional standards and not experimental; reflects an appropriate level of service for which no equally effective, more conservative, or less costly statewide alternative exists; and is not primarily for convenience.
HCPCS code G0281 (electrical stimulation, unattended) is limited to use for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers that are not demonstrating measurable signs of healing after 30 days of conventional care, and then only as part of an appropriate therapy plan of care. Use of G0281 for other wound types or before the 30-day conventional-care trial would not meet the policy limitation and may be noncovered.
Applicable Codes and Coding Guidance
Prior Authorization, Documentation, and Provider Requirements
Prior authorization required — PCP submission and servicing provider exceptions
Prior authorization is required for initial evaluations and therapy visits. The initial evaluation authorization must be submitted by the Primary Care Provider (PCP); if an initial evaluation authorization is already on file, the servicing provider may submit the authorization request for subsequent therapy visits. If no authorization is on file, requests for therapy visits and re-evaluations must be submitted by the referring PCP.
- PCP submits prior auth for initial evaluations for speech, occupational, and physical therapy.
- Servicing provider may submit visit authorization only if an authorization for the initial evaluation was obtained.
- If no authorization on file, PCP must submit requests for therapy visits or re-evaluations.
Codes noted for coverage review — verify authorization/coverage
The policy lists specific CPT/HCPCS codes for reference that may require verification of coverage or prior authorization; inclusion in the policy does not guarantee coverage or payment.
Risk: missing prior authorization leads to claim denial
If prior authorization is not on file before therapy is provided, the therapy claim will be denied.
- Obtain prior authorization before delivering therapy services to avoid claim denial.
Denial risk: non‑medical necessity triggers
Services that are not individualized, inconsistent with the patient’s confirmed diagnosis or symptoms, experimental or investigational, or primarily for convenience may be denied as not medically necessary.
- Ensure services are individualized and consistent with the confirmed diagnosis.
- Avoid providing experimental, investigational, or convenience-oriented services without appropriate justification.
Initial evaluation and evaluation report — PCP order and report contents
Initial evaluation authorization must be submitted by the PCP and include a signed and dated physician order (less than 30 days old). The therapy evaluation report must accompany any authorization request for initial therapy visits and include member identifiers, medical history, functional impairment, diagnosis, prognosis, baseline objective measurements and standardized assessment scores (or task‑analysis documentation if testing not possible).
- Signed and dated physician order <30 days specifying discipline(s) to be evaluated.
- For members <21: current well child visit or exam note; for speech <6 years include hearing screening per Florida EPSTD or documentation if screening not possible.
- Therapy evaluation report must include date of evaluation, member demographics, medical history, functional impairment, prior level vs current, clear diagnosis, prognosis, and baseline objective measurements/standardized scores.
Re-evaluation and continuation — PCP submission, frequency, and required contents
Re-evaluation requests must be submitted by the PCP. Re-evaluations must be completed at least once every five months and the re-evaluation submission must include a signed and dated physician order (<30 days) and documentation of prior authorized visits attended and compliance.
- Current well child exam or visit note documenting face-to-face encounter with PCP at least every six months (when applicable).
- Signed and dated physician order <30 days specifying discipline(s) to be re-evaluated.
- Therapy re-evaluation report must include date of last evaluation, visits authorized vs attended, compliance to home program, objective description of current deficits, and objective demonstration of progress toward each treatment goal.
Plan of care requirements — signed, dated, and complete POC
The plan of care (POC) must be signed and dated by the referring provider (PCP or appropriate specialist) and must be developed from the evaluation results. The POC must include the evaluation date, diagnoses and diagnostic codes, medications/treatments/equipment as applicable, functional limitations, specific therapy to be provided, measurable time‑based goals, frequency/duration, therapeutic methods, coordination, and therapist signature/date.
- POC must be signed and dated by the referring provider (MD, DO, PA, or NP) or appropriate specialist.
- Include evaluation date, diagnosis, medications, functional limitations, therapy specifics, measurable goals, frequency/length/duration, therapeutic methods, monitoring criteria, coordination with other services, and therapist signature/date.
Evaluation/re-evaluation documentation expectations — history, standardized measures, deficits, clinical decision‑making
Evaluations and re-evaluations must document a history and use of standardized tests/measures or, when testing is not possible, task‑analysis and objective clinical information. Documentation must identify current deficits and their severity and include clinical decision‑making complexity.
- Include review of history, standardized assessment scores, age equivalents, percentage of functional delay, criterion‑referenced scores, or other objective data.
- If standardized testing is not possible, provide task analysis, checklists, caregiver reports, and clinical observation to describe deficits.
Denial risk: missing prior authorization — claims denied
Therapy claims will be denied if prior authorization is not on file before services are provided.
- Confirm and document prior authorization prior to providing therapy to prevent claim denial.
Denial triggers for medical necessity — non‑individualized, inconsistent, experimental, convenience
Requests may be denied as not medically necessary if services are not individualized, not consistent with the patient’s confirmed diagnosis or symptoms, experimental/investigational, or primarily for convenience.
- Provide clear documentation linking services to the confirmed diagnosis and individualized treatment needs.
- Avoid services that are experimental, investigational, or for convenience without supporting justification.
Key Definitions
Policy Background
Habilitation, rehabilitation, and maintenance therapy services may be medically necessary in specific circumstances when they meet AHCA’s Medical Necessity criteria. The policy follows AHCA definitions requiring services to be individualized, consistent with diagnosis and symptoms, not experimental, and not provided primarily for convenience. The policy references InterQual outpatient rehabilitation criteria for clinical necessity and excludes cognitive therapy under a separate policy. Documentation, prior authorization, and periodic re-evaluation are required to demonstrate that services meet these standards.
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