Parkland Community Health Plan Therapy Services: What’s New for 2013?

1. Parkland Community Health Plan Therapy Services: What’s New for 2013?

2. Our Mission • Care coordination, physician directed medical care, and whole person care, are foundational elements for Patient Centered Medical Homes (PCMHs) and health homes, which are being widely promoted to improve healthcare quality.   • We believe that having requests for therapy evaluations, originate from primary care physicians (or, in some cases, specialty physicians), based upon developmental screening and other clinical information, will allow for improved outcomes for our members. • Encourage focus on the whole person, and coordination of care, with other community resources, such as Early Childhood Intervention, Head Start, Preschool Program for Children with Disabilities, and public schools. • Will result in more efficient, effective care, and increased patient/family satisfaction.

3. Medical Necessity • appropriate for the symptoms and diagnosis or treatment of the patient’s condition, illness, disease or injury; and • provided for the diagnosis or the direct care of the patient’s condition, illness, disease or injury; and • in accordance with current standards of good medical practice; and • not primarily for the convenience of the patient or provider; and • the most appropriate supply or level of service that can be safely provided to the patient Medicare Report 2000

4. Our Goals • Improve: 1. quality of care 2. member outcomes 3. member/parent satisfaction with care 4. provider satisfaction - therapists and primary care providers/specialists • Facilitate communication between: 1. Primary care providers 2. Therapists 3. Health plan • Fulfill obligations to all stakeholders 1. HHSC 2. member/parents 3. providers

5. Initial Evaluations • Now require pre-authorization • Must be accompanied by clinical information from the primary care provider (PCP) documenting medical necessity for the evaluation • This clinical information will typically be based upon the results of developmental screening which is part of the TH Steps visits (routine well-child care)

6. Initial Therapy • Requests evaluated individually based upon medical necessity • Test scores should be submitted as standard scores, not raw scores, age-equivalent, or percentiles • Qualifying standardized test scores: 1. If mean is 100, score < 1.5 SD or <75 2. If mean is 10, score < 1.33 SD or <6 • Provision of a home/family program should be included in the treatment plan with frequency/intensity specified

7. Therapy Re-Evaluations Speech Physical/Occupational • Re-evaluations for ongoing therapy do not require prior authorization • No distinct CPT code for re-evaluations vs. initial evaluations (92506) • Speech therapy requests for ongoing care will be subject to medical necessity review • Re-evaluations for ongoing therapy - physical (97002) and occupational (97004) do not require prior authorization • Requests of continuationof therapy will be subject to medical necessity review.

8. Therapy Continuation • Requests must be accompanied by updated clinical information documenting medical necessity- 1. evidence of progress and carryover of therapy skills into the member’s natural environment, 2. provision of a home program and performance of that by the member/parent • Repeat standardized testing, utilizing the same instrument which was used at the previous evaluation(s) is required if about 6 months have elapsed since previous testing (More frequent testing may be required by the Medical Director). • Exception is if child has aged out of previously used test

9. Care Coordination-The Role of Therapists • Texas Medicaid Provider Procedures Manual sec. 2.5 All health-care professionals are required by federal and state regulations to refer children who are 35 months of age and younger (i.e., before their third birthday) to the Texas ECI Program within two business days of identifying a disability or suspected delay in development. Referrals can be based on professional judgment or a family's concern. A medical diagnosis or a confirmed developmental delay is not required for referrals. • Coordinate with school districts to assure that Children with Special Healthcare Needs (CSHCN) are receiving the maximum services to which they are entitled. This also ensures continuity of services if their Medicaid/CHIP eligibility lapses. • Refer CSHCN to Head Start or to school districts for inclusion in their Preschool Programs for Children with Disabilities (PPCD).