Physical Occupational and Speech Therapy Guideline

PA Submission and In-Network Evaluation Rules

Submit all physical, occupational, and speech therapy prior-authorization requests to Utilization Management by fax, mail, or electronic submission during normal business hours. Initial evaluations and re-evaluations do not require prior authorization when performed by an in-network provider.

• In-network therapy evaluations: no PA required.
• In-network re-evaluations: no authorization required.

Out-of-Network Evaluation Authorization

Out-of-network therapy evaluations require documentation supporting the medical necessity of the evaluation and an order from an in-network practitioner.

• Signed order dated within 60 days before the evaluation date.
• Physician or physician-extender visit note identifying the need, or a letter of medical necessity signed by the ordering physician.

PA Timing Windows

Submit PA requests within the applicable timing windows to avoid retrospective review or processing delays.

• Requests must be received no later than 7 calendar days after the start of care; later requests are retrospective and follow the TCHP Retrospective Review Procedure.
• Initial requests may be submitted no earlier than 60 days before the service start date.
• Ongoing requests may be submitted no earlier than 30 days before the current authorization period expires.

Adult Therapy Authorization Limits

For members age 21 and older, acute therapy is limited to the shorter of the maximum benefit period or the applicable authorization limit. Chronic therapy and home speech therapy are not covered adult benefits.

• Maximum of 120 days per identified acute condition or acute exacerbation, or until maximum benefit is achieved, whichever comes first.
• Each authorization period may approve up to 60 days based on the acute condition.
• Chronic therapy is not a benefit for adults; speech therapy provided in the home is excluded for adults.

ECI Authorization Exception

Early Childhood Intervention (ECI) services do not require prior authorization, but they must comply with the Texas Medicaid Provider Procedures Manual Children’s Services Handbook.

Authorization and Ordered Frequency Requirements

Obtain prior authorization when increasing frequency or adding services that require separate authorization. Requested frequency and dates must remain within the prescribing provider’s order or signed evaluation plan of care.

• A revision request may be considered through the end of the current approved authorization period.
• Extending dates solely to accommodate missed visits is not an authorization revision.

Timing of Revision Requests

Submit revision requests no later than the end of the current approved prior-authorization period. Requests to extend dates only because of missed visits are handled as ongoing-treatment requests rather than revisions.

Transfer Timing Requirements

Transfer requests submitted after the previous authorization end date must satisfy the documentation and submission requirements for the specific service type.

• Transfer requests submitted within the same month as enrollment are not considered retrospective.
• For services approved by another MCO or TMHP, include the prior authorization letter; coverage is honored for the shorter of 90 days or the prior authorization’s expiration, subject to the in-network exception for the original authorization duration.

Initial Request Documentation

For an initial treatment request, submit a completed Texas Medicaid Prior Authorization Form signed and dated within 60 days of submission by both the therapist and prescribing provider. The request must specify the requested frequency and duration.

• If the prescribing provider has not signed the form, include a signed and dated written order, prescription, or documented verbal order.
• A prescribing provider’s signature on the therapy plan of care may satisfy the form or order requirement.
• Frequency and dates may not exceed the signed provider order or evaluation plan of care.

Order and Plan-of-Care Requirements

The initial evaluation and treatment plan or plan of care must document the member’s medical history, prior therapy, related diagnoses, primary language, onset or exacerbation date, current function assessed within 60 days, baseline objective measures, diagnosis, prognosis, modalities, frequency, duration, goals, equipment, home program, requested dates, applicable coordination, and therapist signature/date.

• Plans must describe expected frequency changes during the requested treatment period.
• Include specific short- and long-term functional goals and guardian involvement in the home exercise program.
• Coordinate with ECI, Head Start, or SHARS when applicable.

Recertification Authorization Documentation

Recertification requests require the same current PA form, provider order, and frequency limitations as initial requests, plus documentation appropriate to acute or chronic therapy.

• The form must be signed and dated within 60 days of submission by the therapist and prescribing provider, or be accompanied by a compliant order or verbal order.
• Frequency and dates may not exceed the signed provider order or evaluation plan of care.

Acute Therapy Progress Summary

For acute therapy recertification, provide a signed and dated progress summary showing response to treatment, objective progress for each goal, updated measurable goals and time frames, prognosis, participation and home-program adherence, and continued medical need.

• The summary must be signed and dated by the responsible therapist.

Chronic Therapy Re-Evaluation Documentation

For chronic therapy, complete a formal re-evaluation and treatment plan or plan of care every 180 days, or sooner when the member’s status changes. Routine session reassessments, progress reports for extensions, and discharge summaries do not replace a comprehensive re-evaluation.

• Document current function assessed within 60 days, developmental delay and continued medical need, prognosis for measurable progress, updated goals, prior progress, equipment, home program, dates, coordination, and therapist signature/date.
• Include medical and therapy history, related diagnoses, onset date, and therapy start date.

Developmental-Delay Testing Documentation

Developmental-delay requests must use age-appropriate, norm-referenced, standardized tests specific to the therapy. Retest every 180 days using the same instrument when appropriate, and explain any change in instrument.

• Initial eligibility generally requires a score at least 1.5 standard deviations below the mean in a subtest or composite area, with raw scores and standard-deviation scores reported.
• For scores below 1.5 SD initially or 1.33 SD for ongoing therapy, include a criterion-referenced test and informed evidence-based clinical opinion.
• If standardized testing cannot be completed, document why, describe functional abilities and deficits, and provide measurable short- and long-term goals.
• For children born before 37 weeks, use adjusted age through 24 months; adjustment may not exceed 16 weeks.

Bilingual Speech Documentation

Speech requests for bilingual or multilingual members must identify the member’s primary language, other languages spoken at home, and the language of therapy. Do not expect equivalent proficiency in both languages.

• When possible, use culturally and linguistically adapted equivalents in both languages and include both results.
• Use the higher score to determine qualification and treatment language; subsequent re-evaluations should be conducted only in the therapy language.
• Criterion-referenced tools may be used to identify strengths and weaknesses.

Speech-Specific Supporting Documentation

Speech-specific requests must include documentation matched to the disorder and applicable eligibility pathway.

• For articulation, address conversational intelligibility when standardized scores do not match functional intelligibility and report age-specific intelligibility findings.
• For swallowing or feeding, provide an in-depth functional profile of oral-motor structures and function.
• For voice, include a medical evaluation on the initial request and a medical referral.

Prior Authorization Form and Provider Order

Submit the Texas Medicaid Prior Authorization Form and the prescribing provider’s order or compliant verbal order for initial, ongoing, and revision requests. The form must specify frequency and duration and be signed and dated within 60 days of submission.

• A prescribing provider’s signed plan of care may satisfy the form or order requirement.
• Requested frequency and dates cannot exceed the signed order or plan of care.

Acute Therapy Recertification Documentation

Acute therapy recertification must include a current progress summary with objective, goal-specific evidence of functional improvement and continued skilled need.

• Include response to therapy, current plan, updated goals and time frames, prognosis, participation, home-program adherence, and therapist signature/date.

Chronic Therapy Re-Evaluation and Plan of Care

Chronic therapy recertification requires a formal re-evaluation and updated plan of care every 180 days or sooner if status changes, including prior-period goals and progress and new measurable goals.

• Include current function, developmental-delay support when applicable, prognosis, treatment frequency changes, equipment, home program, requested dates, coordination, and therapist signature/date.

Change of Therapy Provider

When therapy moves to a new provider outside the current group or agency during an authorized period, the new provider must submit a new authorization request and a new evaluation meeting established requirements.

• Include a change-of-therapy-provider letter signed by the member or responsible adult.
• The letter must state the last date of service with the previous provider and identify the previous and new providers.
• A provider change within the same enrolled group may use the existing evaluation and plan of care; no change letter is required and the authorization period does not change.

Continuity of Care Documentation

For continuity of care from another MCO or TMHP, include the previously approved authorization letter and submit the transfer request under the applicable timing and service documentation rules.

• Authorization is generally honored for the shorter of 90 days or the previous authorization’s expiration.
• For an in-network provider, TCHP honors the original authorization duration even when it extends beyond 90 days.

Revision Request Documentation

Revision requests must explain the medical rationale for the change and include an updated plan of care addressing the prior plan and all revised services.

• Include a progress summary, updated or new measurable short- and long-term goals with time frames, and prior authorization-period goals and progress.
• The updated plan of care must be signed and dated by the responsible therapist.
• A revision is required for increased frequency or separately authorized services.

Co-Treatment and Group Therapy Requirements

Co-treatment and group therapy must follow current Texas Medicaid Provider Manual guidance. Co-treated disciplines may not duplicate services and must reflect each discipline’s distinct expertise.

• Physical, occupational, and speech therapists must use separate evaluations, treatment plans, and goals.
• Group therapy must follow the applicable handbook requirements.

PPECC Coordination

When therapy is provided in a prescribed pediatric extended care center (PPECC), the therapy provider must provide evidence of care coordination with the PPECC provider.

Diagnosis Alone Does Not Establish Medical Necessity

A diagnosis alone does not establish medical necessity for physical or occupational therapy. The record must demonstrate a specific, effective, skilled treatment related to the member’s acute or chronic condition and functional impairment.

• Document functional goals, skilled therapist judgment, and treatment related to the medical condition rather than member or provider convenience.
• Home therapy requires documentation supporting medical need and the appropriateness of the prescribed service, equipment, or supply.

No Skilled Functional Need or Reasonable Benefit

Therapy may be denied when the service does not require the unique knowledge, skills, and judgment of a licensed therapist or is not expected to provide a reasonable practical benefit.

• The service must be part of an active skilled plan of treatment and require qualified-provider judgment because of the condition’s complexity.
• Document expected improvement, maintenance of function when appropriate, and the skilled education or training provided.

Insufficient Progress or Restoration Potential

Ongoing therapy is at risk when documentation does not objectively show progressive functional improvement or significant restoration potential within a reasonable and predictable period.

• Show that function is not reasonably expected to improve through ordinary resumption of activities.
• Document measurable progress over specific time frames and restoration potential proportionate to the requested therapy.

Developmental-Delay Testing Does Not Meet Threshold

Developmental-delay eligibility is not established when standardized testing does not meet the applicable threshold or when required supporting evidence is absent.

• Initial therapy generally requires at least 1.5 SD below the mean; ongoing therapy uses the 1.33-SD threshold.
• When scores are above the applicable threshold, include criterion-referenced testing and informed evidence-based clinical opinion if seeking to support medical necessity.

Incomplete Alternative Assessment Documentation

Do not rely on incomplete alternative assessment documentation when a member cannot complete standardized testing.

• Document why the norm-referenced assessment could not be used.
• Include a functional description of abilities and deficits, measurable short- and long-term goals, and relevant test results.

Adult Chronic or Home Speech Therapy Exclusion

Chronic therapy is not a benefit for members age 21 and older, and home speech therapy is excluded for adults.

• Adult therapy is limited to medically necessary acute treatment or acute exacerbation of a chronic condition.
• Acute/recent conditions must generally be documented as occurring within 90 days of the prescribing provider’s evaluation.

Audio-Only Telehealth Exclusion

Synchronous telephone or audio-only technology is excluded from coverage. Covered telehealth must comply with the current Texas Medicaid manuals, including services required to be delivered in person.

Untimely Prior Authorization Submission

PA requests received more than 7 calendar days after the start of care are retrospective and will be processed under the TCHP Retrospective Review Procedure.

• Submit initial requests no earlier than 60 days before the start date and ongoing requests no earlier than 30 days before the current authorization expires.

Unacceptable Signature Format

Only electronic or wet signatures are accepted on PA forms and supporting documentation.

• Stamped signatures, typed fonts, and images of wet signatures are not accepted.

No Remaining Skilled Medical Need

Ongoing therapy may not be approved when the member no longer has a skilled medical need or has achieved the treatment-plan goals or maximum functional benefit.

• The member may have returned to baseline, reached normal function, or be able to maintain status with a home program.
• Adaptation to equipment with age-appropriate ADL performance and minimal or no caregiver assistance may support discontinuation.

Participation or Developmental Criteria No Longer Met

Therapy may be discontinued when participation or developmental criteria are no longer met.

• The member may be unable to participate because of medical, psychological, or social complications when therapist skills are no longer needed and the responsible adult has been instructed in the home program.
• Testing may show that developmental delay is no longer present; all scores improved to within 1.33 SD of the mean, including at least 80 for tests with a mean of 100 or at least 7 for tests with a mean of 10.

Plateau or Inadequate Progress

A plateau or inadequate progress toward therapy goals may support denial, therapeutic pause, or transition to maintenance therapy for members under age 21.

• Document limited or stopped progress, slow goal attainment, barriers to participation, and any continuing skilled need to maintain progress or prevent deterioration.
• Failure to make significant progress toward goals or improvement on standardized scores may result in discontinuation.

Attendance or Home-Program Noncompliance

Poor attendance or noncompliance with therapy or the home treatment program may prevent continued authorization.

• Document member and responsible-adult participation and adherence.
• Address barriers and the education provided regarding the home program.

Noncovered or Non-Skilled Therapy

Therapy is not covered when it does not require the skills of a licensed therapist or is primarily routine, repetitive, educational, recreational, conditioning, or maintenance activity after maximum improvement.

• Examples include massage, general range-of-motion or fitness exercises, repetitive gait practice, athletic performance, weight-loss exercise, and activities the member or responsible adult can perform independently.
• Services by a member’s responsible adult and instruction solely for other agency or professional personnel are not covered.

Unproven, Educational, or Nonmedical Treatment

Treatments without supporting peer-reviewed medical literature, as well as educational or nonmedical interventions, are not covered benefits.

• Examples of unproven treatments include sensory integration, vestibular rehabilitation for ADHD, anodyne, craniosacral, interactive metronome, cranial electrostimulation, low-energy neurofeedback, and Wilbarger brushing.
• Excluded purposes include emotional or behavioral readjustment, psychotherapy adjuncts, classroom learning skills, self-correcting articulation errors, and natural disfluency in young children.
• VitalStim is not separately reimbursable and must be part of comprehensive feeding treatment.

Bilingualism Alone Is Insufficient for Developmental-Delay Coverage

Bilingualism alone is not developmental delay and is not sufficient to establish coverage for speech therapy.

• Document other qualifying speech criteria and assess the member’s strengths and deficits in a culturally and linguistically appropriate manner.
• Use the applicable bilingual testing and therapy-language requirements.