NC Medicaid Simplifies Authorization of Therapy for Adults
North Carolina Medicaid has recently simplified its PT/OT authorization rules for patients who are 21 and older. https://files.nc.gov/ncdma/documents/files/10-A_3.pdf All of the prior rules limiting the number of visits based on diagnosis have been removed.
The following is a summary of the new rules:
• No prior authorization (PA) is needed for evaluation visits or for treatment rendered as part of an evaluation visit (as long as the treatment is warranted based on the evaluation results). However, NC Medicaid will only pay for the initial eval and not any additional amount for treatment provided during the initial eval.
• Prior approval is required at the start of all other treatment services.
• The first PT request within a calendar year can be for no more than three treatment visits and those visits must be completed within one month. You can get a PA for these three treatment visits to begin as early as the day following the submission of the PA request. Also, if the patient will be using these three visits within, for example, the first two weeks, you do not need to wait 30 days to obtain the PA for additional visits.
• After the first three treatment visits are used, you can obtain an additional PA for up to 12 therapy treatment visits which must be completed within six months.
• After the first 15 visits, you can obtain one more PA for an additional 12 visits which also must be completed within six months.
• A beneficiary can receive a maximum of 27 therapy treatment visits per calendar year across all therapy disciplines combined (OT, PT, ST).
• When requesting a PA for additional visits, the PA contractor will be looking for quantitative measures or objective details reflecting the effectiveness of treatment already provided.
• It is important to clearly document all “treatment” visits completed in the time period already authorized. The PA contractor relies on reports from providers to determine the visit count. If a PA request is submitted with time remaining on the current authorization, the PA contractor will ask for updated information about anticipated visits if this is not addressed in the Comment Section.