PT/OT Evaluation

CPT:
97161, 97162, 97163,
97165, 97166, 97167

Modifier:
GP for PT
GO for OT

1. A PA is not required for an evaluation. Each member is entitled one evaluation charge per year.

1. Treatment PA request needs to be submitted within 30 days of completing the evaluation to avoid the need for a progress note visit.

PT/OT Treatment Request

CPT:
97110, 97112, 97113, 97116, 97124, 97140, 97150, 97164/97168, 97530, 97535, 97602, 97022, 97532, 92526

Modifier:
GP for PT
GO for OT 

1. HCA-61 form.

2. SC-15 Parental Consent form or clinic’s own equivalent.

3. Evaluation note - if initial request.

4. Progress note – if request is to continue services within the year of above evaluation.

5. Rx for services or 
SC-10 Referral form.

6. Above requirements apply for the re-evaluation CPT codes as well.

2. Request cannot exceed one year from parental consent.


3-4. One of these is necessary, and the request needs to be submitted to start within 30 days of completion of either note to avoid the need for another up-to-date note.




5. Request cannot exceed one year from the signed date on the Rx.

6. Re-evaluation CPT code can be used when there is a significant change in status requiring additional evaluative services. This code can be listed as a line-item and can be claimed once at least 6 months after the evaluation.

PT/OT Equipment-Related Request

CPT:
97542, 97535, 97755,
97760, 97761, 97763

Modifier:
GP for PT
GO for OT

1. HCA-61 form.

2. SC-15 Parental Consent form or clinic’s own equivalent (if available).

3. Rx for equipment-specific services.

4. Statement from therapist of record.

5. If any CPT codes from the treatment request are present, refer to the box above.

2. Provide if available. Request cannot exceed one year from parental consent.



3. Request cannot exceed one year from the signed date on the Rx.

4. Statement needs to elaborate that services are being sought to meet equipment needs only (listed CPT codes).

5. If treatment is being provided beyond what is needed for equipment needs, then apply the requirements/limitations from the box above.

PT/OT Transfer-Back Request

1. HCA-61 form.

2. SC-15 Parental Consent form or clinic’s own equivalent.

3. Rx for services.

4. SoonerSelect CE approval letter.

5. Evaluation note - submitted to the SoonerSelect CE for initial authorization.

6. Progress note – showing patient’s status during the transfer period.

1-4. All transfer-back PA requests will be approved, upon meeting documentation requirements, for a period of up to 90 days or the original end-date of the SoonerSelect CE approval letter, whichever period is shorter. The end date will also be reduced based on the year timeline of parental consent form and Rx for services. The SoonerSelect CE approval letter must be sufficiently detailed to allow a retro start date.  

5-6. An evaluative or progress note completed 30 days before the transfer-back, or a progress note completed any time after the transfer-back date will be necessary.

PT/OT Change of Provider Request

1. HCA-61 form.

2. SC-15 Parental Consent form or clinic’s own equivalent.

3. Evaluation note or progress note from the previous clinic.

4. Current progress note from the new clinic.




5. Rx for services.

6. SC-16 Change of Provider form.

2. Request cannot exceed one year from parental consent.

3-4. An evaluative or progress note completed within the past 30 days is necessary. This note can be from the previous clinic (per appropriate handoff) or new clinic if continuing care under the established POC after the length of time. The new clinic can perform a new evaluation being mindful of the yearly reimbursement.

5. Request cannot exceed one year from Rx.

6. New clinic is responsible for ensuring that the family has communicated this provider change with the previous clinic. If not, please ensure that the previous clinic is aware that care is now to continue at your location.

PT/OT TEFRA Request

1. HCA-61 form.

2. SC-15 Parental Consent form (if available).

3. Evaluation note or progress note completed prior to the historic start date.

4. Rx for services.

5. TEFRA award letter granting retroactive eligibility.

6. A current progress note.

1. Needs to reflect the historic start date and the future end date and account for the entirety of services.

2. If available, consent form does not need to be OHCA- specific.

3. The evaluation or progress note that was performed up to 30 days before the historic start.

4. Rx needs to be signed/dated before the historic start date.

5. Submission should be timely once the family provides the clinic with a copy of this letter.

6. A current progress note from within the past 30 days is necessary if services are to not only be retroactive but also seek coverage for the future.

PT/OT Amendments

1. HCA-60 Amendment form.


2. A current progress note from the past 30 days will be necessary if the request seeks additional coverage: extending timeline, adding units, adding line-items or changing CPT codes.

1. This form must indicate the absolute changes(s) being sought. Check boxes for all applicable changes being sought.

2. Requests for additional coverage must be submitted within the authorization timeline. A new PA request must be submitted after the authorization timeline.