CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Speech Therapy 01.01.21 To 03.31.21

Policy governs coverage, limits, exclusions, documentation and billing for speech-language pathology (speech therapy) services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines for Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySpeech Therapy 01.01.21 To 03.31.21

Policy CodePolicy N/A

Change TypeRevised (benefit limits/prior authorization updates)

Effective DateOct 1, 2020

Next Review Date

Key ActionFor INTEGRITY, obtain prior authorization for any sessions beyond 24 per calendar year and verify plan-specific prior authorization requirements on the Prior Authorization Reference page.

SourceLink

POLICY UPDATE CHANGES

01/01/21 Policy Updates: Benefit limit/prior authorization requirements for Commercial and INTEGRITY. Medicaid limit updated to calendar year instead of rolling year.

11/05/20 Policy Review/Approval Date for 1/1/21 changes.

10/01/20 Policy Effective Date.

09/14/20 Policy Review/Approval Date.

24Annual session limit

3Early Intervention referral age (years)

11CPT/HCPCS codes listed

Coverage Summary

This policy governs coverage, limits, exclusions, documentation, and billing for speech-language pathology (speech therapy) services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines for Neighborhood Health Plan of Rhode Island. Speech-language therapy services evaluate and treat communication, cognitive-linguistic, feeding, and swallowing impairments tied to illness, injury, congenital, or neurodevelopmental conditions. All services must be medically necessary, meet applicable coding and documentation standards, and comply with plan-specific authorization requirements.

The policy intent is to ensure services are evidence-based, recommended by a medical provider for a specific condition or deficit, and designed with treatment goals that provide a reasonable expectation of measurable improvement within a reasonable and predictable time frame. Providers are responsible for verifying eligibility, coverage, and prior authorization requirements before rendering services.

Quick Facts

Annual session limit24

Early Intervention referral threshold (years)3

Referenced CPT/HCPCS codes11

Medical-Necessity Criteria

Medically Necessary Speech Therapy

Rehabilitative speech services are covered when ALL of the following are met:

ALL of the following

Speech-language therapy services assist with development of human communication and evaluate/treat speech, language, cognitive-linguistic, feeding, or swallowing impairments related to a specific illness, injury, or congenital or neurodevelopmental condition
Recommended by a medical provider to address a specific condition, deficit, or dysfunction
Treatment modalities are expected to be evidence-based and available within the Neighborhood network
Treatment goals must systematically address a specific diagnosis, deficit, or dysfunction with a reasonable expectation of measurable improvement in a reasonable and predictable period of time

Medical necessity: All services must be medically necessary to qualify for reimbursement; Neighborhood may use NCD, LCD, Interqual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity

Providers must verify eligibility, coverage and authorization prior to rendering services

Age-specific referral

Children up to age three (3) years with developmental delays and related conditions should be referred to Early Intervention for evaluation and treatment prior to requesting services from Neighborhood

Coverage Limits by Product

Medicaid: Covered without prior authorization and limited to 24 sessions per calendar year24 sessions per calendar year

Medicaid limit updated to calendar year (01/01/21)

INTEGRITY: Covered without prior authorization for 24 sessions per calendar year; any additional sessions require prior authorization24 sessions per calendar year

Any sessions beyond 24 per calendar year require prior authorization

Commercial: Covered without prior authorization and limited to 24 sessions per calendar/plan year24 sessions per calendar/plan year

Benefit limit/prior authorization updates effective 01/01/21

Definition of a Session

Session definition: A speech therapy session is generally defined as face-to-face time with the patient for a length of time compliant with nationally recognized professional speech-language pathology standards for a typical session

Exclusions / Not Medically Necessary

Not Covered

Speech services are not covered when ANY of the following apply:

Exclusions: Therapy for a condition when the therapeutic goals of a treatment plan have been achieved and no progress is apparent or expected to occur

Exclusions: Therapy performed in group settings

Group therapy is not covered

Exclusions: Non-skilled services that do not require the skills of a qualified provider or procedures that may be carried out effectively by the child, family, or caregivers

Exclusions: Maintenance programs, including drills, techniques and exercise that preserve the child's present level of function and prevent regression

Exclusions: Swallowing/feeding therapy for food aversions or food selectivity not resultant from an underlying medical condition or neurodevelopmental disorder, unless there is weight loss and risk of failure to thrive

Exclusions: Oral sensorimotor therapy or myofunctional therapy as isolated therapy for tongue thrust, deviant/reverse swallow or oral myofunctional disorders in members without a diagnosed neuromuscular disease

Exclusions: Vocational rehabilitation, testing and screening focusing on job adaptability or job placement

Exclusions: Rehabilitative services to restore function for a member's specific occupation

Exclusions: Services provided solely for the convenience of the member or service provider

Exclusions: Services associated with use of Altered Auditory Feedback (AAF) devices, including the devices

Exclusions: Conditions appropriate for behavioral management rather than medical/rehabilitative therapies will be referred appropriately

Exclusions: Services that would result in the individual receiving duplicative or substantially identical services as those provided by another Medicaid funded service

Coding

Covered/Relevant CPT/HCPCS CodesCPT|HCPCSCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance
92526	Treatment of swallowing dysfunction and/or oral function for feeding
92607	Evaluation for prescription for speech-generating AAC device, face-to-face; first hour
92608	Evaluation for prescription for speech-generating AAC device; each additional 30 minutes (add-on)
92610	Evaluation of oral and pharyngeal swallowing function
S9152	Speech therapy, re-evaluation

Group Therapy - ExcludedCPTNot Covered

92508

Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals (policy states therapy performed in group settings is not covered)

Provider Actions

Prior Authorization

Prior authorization for excess sessions (INTEGRITY and others)

For INTEGRITY, any sessions beyond 24 per calendar year require prior authorization; providers should verify prior authorization requirements on plan-specific Prior Authorization Reference page.

24-session threshold: 24 sessions per calendar year; additional sessions for INTEGRITY require prior authorization.
Providers must verify plan-specific prior authorization requirements on Neighborhood's Prior Authorization Reference page.

Documentation Required

Medical record documentation and medical necessity

Providers must maintain documentation supporting billed services and medical necessity and Neighborhood may request medical records; documentation must follow CMS standards.

Documentation must support services billed and the medical necessity of those services.
Records may be requested by Neighborhood for any billed service.
Documentation must follow CMS standards.

Billing Rule

Timely filing and claim submission

Submit complete claims within contractual timely filing guidelines; coding must meet CPT, ICD-10-CM, and HCPCS standards.

Coding must comply with CPT, ICD-10-CM, and HCPCS Level II standards.
Submit complete claims within contractually determined timely filing guidelines.
Adjustments, corrections, and reconsiderations must include required forms and follow National Claims Standards.

Denial Risk

Denial for non-covered services

Claims may be denied if services meet listed exclusions, are duplicative of other Medicaid-funded services, or lack documentation of medical necessity.

Common exclusion triggers: therapeutic goals already achieved with no progress expected; maintenance programs; non-skilled services; therapy performed in group settings.
Services associated with Altered Auditory Feedback (AAF) devices are excluded.
Services that would duplicate other Medicaid-funded services may be denied.
Claims lacking documentation of medical necessity or supporting records may be denied.

Definitions & Background

Speech-language therapy evaluates and treats impairments in communication, speech, language, cognitive-linguistic function, feeding, and swallowing that are related to a specific illness, injury, or congenital or neurodevelopmental condition. The scope includes diagnostic evaluation, treatment, and re-evaluation consistent with nationally recognized professional speech-language pathology standards.

Services are covered when recommended by a medical provider for a specific condition or deficit, and when treatment modalities are evidence-based and available within the Neighborhood network. Treatment goals must systematically address the diagnosis/deficit with a reasonable expectation of measurable improvement in a reasonable and predictable period of time. Children ≤ 3 years with developmental delays should be referred to Early Intervention prior to requesting Neighborhood services.

Coverage limits vary by product but generally allow up to 24 sessions per calendar year without prior authorization (Medicaid, INTEGRITY, Commercial); INTEGRITY requires prior authorization for sessions beyond 24. A speech therapy session is defined as face-to-face time with the patient compliant with nationally recognized professional standards.

The policy lists exclusions including therapy when goals have been achieved with no expected progress, group therapy, non-skilled services, maintenance programs, certain feeding/swallowing therapy for selective eating without medical cause (unless weight loss/failure to thrive), isolated oral sensorimotor/myofunctional therapy without neuromuscular disease, services associated with Altered Auditory Feedback (AAF) devices, vocational or occupation-specific rehabilitation, convenience services, and services duplicative of other Medicaid-funded services.

Relevant CPT/HCPCS codes referenced include assessment and treatment codes (e.g., 92507, 92521–92526, 92607–92610, S9152) and the policy notes group therapy code 92508 is not covered when performed in group settings.

Policy updates effective 01/01/21 revised benefit limits and prior authorization requirements across products and changed Medicaid from a rolling year limit to a calendar year limit.

Definitions

SessionFace-to-face time with the patient compliant with nationally recognized professional speech-language pathology standards for a typical session.

Revision History

01/01/21material revisionLatest

Policy Updates: Benefit limit/prior authorization requirements for Commercial and INTEGRITY. Medicaid limit updated to calendar year instead of rolling year.

11/05/20review

Policy Review/Approval Date for 1/1/21 changes.

10/01/20policy effective date

Policy Effective Date.

09/14/20review

Policy Review/Approval Date.