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Frequency and Duration Criteria
Frequency must always be commensurate with the patient’s medical and skilled therapy needs, level of disability and standards of practice; it is not for the convenience of the patient or the responsible adult.
Exceptions to therapy limitations may be covered if the medically necessary criteria are met for the following:
When therapy is initiated, the therapist must provide education and training of the patient and responsible caregivers, by developing and instructing them in a home treatment program to promote effective carryover of the therapy program and management of safety issues.
Requests for Services
Providers may request high, moderate, or low frequencies on the Texas Medicaid Physical, Occupational or Speech Therapy (PT, OT, ST) Prior Authorization Form by indicating 3, 2, or 1 time per week respectively. Providers may request low or maintenance level by requesting 1, 2, or 3 times per month. Additional documentation is required when requesting a frequency of 3 times a week or more.
Providers may request physical, occupational, or speech therapy services frequency by week for one or more visits per week, or by month for 1, 2, or 3 visits per month.
Missed visits may be made up within the authorization period as long as total number of visits or units authorized does not exceed the amount authorized. Provider should document reason for visits outside of the weekly or monthly frequency in the patient’s medical record.