The NC Department of Health and Human Services has modified its policy regarding prior authorization of PT/OT for patients who are 21 or over. Please note that this change will not affect authorizations for patients covered by managed Medicaid plans.
This modification is in Section 5.4 of the Clinical Coverage Policy 10A.
Prior policy
The first prior approval request within a calendar year shall be for no more than three therapy treatment visits and one month. The PA review vendor will authorize these three treatment visits to begin as early as the day following the submission of the PA request. Any subsequent PA may be obtained for up to 12 therapy treatment visits and six months. A beneficiary can receive a maximum of 27 therapy treatment visits per calendar year across all therapy disciplines combined (occupational therapy, physical therapy and speech/language therapy).
New policy
Prior Authorization (PA) can be obtained for up to 12 therapy treatment visits and six months in a single PA request. Each reauthorization request must document the efficacy of treatment. Annual treatment visits must be medically necessary and are available to beneficiaries 21 years and older for a total maximum of 30 treatment visits per calendar year combined across occupational and physical therapy rehabilitative services.
