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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyDell Children's Telehealth Therapy Coverage | Open…
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    CurrentDell Children's Health PlanPolicy N/A

    H.B. 4 Interim Guidance: Physical Therapy, Occupational Therapy, Speech Therapy Services

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    Interim guidance for reimbursement of medically necessary physical, occupational, and speech therapy delivered through synchronous audio-visual telehealth under Texas Medicaid; MCO administrative and billing procedures may vary.

    Policy Summary
    PayerDell Children's Health Plan
    PolicyH.B. 4 Interim Guidance: Physical Therapy, Occupational Therapy, Speech Therapy Services
    Policy CodePolicy N/A
    Change TypeRevised interim guidance
    Effective DateFebruary 1, 2022
    Next Review DateN/A
    Key ActionContact the client's specific MCO to confirm prior authorization, referral, claims, and telehealth billing requirements.
    SourceLink
    POLICY UPDATE CHANGES

    Certain COVID-19 telehealth flexibilities for physical, occupational, and speech therapy are transitioned to interim guidance aligned with House Bill 4.

    The COVID-19 notice titled 'Claims for Telehealth Service for Occupational, Physical, and Speech Therapy' is ended.

    Medicaid MCOs must provide medically necessary Medicaid-covered services, but prior authorization, referrals, precertification, and claims or encounter filing procedures may differ by MCO.

    3Therapy disciplines addressed
    Synchronous audio-visualCovered delivery modality

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    MCO-specificAdministrative requirements

    Eligible Telehealth Therapy Services

    Synchronous audio-visual PT, OT, and ST telehealth reimbursement

    Telehealth reimbursement applies when all of the following criteria are met:

    ALL of the following

    • ONE of

      • ALL of the following

        • Physical therapy

          • The service is physical therapy.
      • The service is occupational therapy.
      • The service is speech therapy.
    • The service is medically necessary.
    • The client is eligible for Medicaid.
    • The service is Medicaid-covered.
    • The service is delivered through synchronous audio-visual technology.
    • The claim follows the client's applicable Medicaid managed care organization requirements, including any requirements for prior authorization, precertification, referrals, claims or encounter filing, and permitted procedure codes.

    Telehealth Billing and MCO Verification

    Prior Authorization

    Verify MCO-specific administrative requirements

    Contact the client’s specific Medicaid managed care organization before billing to confirm the administrative requirements for telehealth therapy services.

    • Verify whether prior authorization, pre-certification, or referrals are required.
    • Confirm the applicable claims or encounter data filing procedures, which may differ from fee-for-service and from MCO to MCO.
    Billing Rule

    Confirm telehealth-billable services and codes

    Confirm with the client’s specific MCO which therapy services and procedure codes are permitted to be billed using telemedicine or telehealth modalities.

    Policy Summary
    PayerDell Children's Health Plan
    PolicyH.B. 4 Interim Guidance: Physical Therapy, Occupational Therapy, Speech Therapy Services
    Policy CodePolicy N/A
    Change TypeRevised interim guidance
    Effective DateFebruary 1, 2022
    Next Review DateN/A
    Key ActionContact the client's specific MCO to confirm prior authorization, referral, claims, and telehealth billing requirements.
    SourceLink
    On This Page
    Eligible Telehealth Therapy ServicesTelehealth Billing and MCO Verification
    Billing Rule

    Submit eligible synchronous audio-visual therapy claims

    Submit claims for medically necessary, Medicaid-covered physical, occupational, and speech therapy services delivered through synchronous audio-visual telehealth, following the applicable MCO’s procedures.

    • Applicable disciplines: physical therapy (PT), occupational therapy (OT), and speech therapy (ST).
    • The interim guidance applies to services provided by synchronous audio-visual technology.