PT Jobs / Career Center
Community Search
Print Page   |   Contact Us   |   Your Cart   |   Sign In   |   Register
Community Search
News & Press: General

HHSC Guidance on the Provision of Medicaid PT/OT/ST by Managed Care Organizations

Tuesday, May 1, 2018   (0 Comments)
Posted by: Lindsey Green
Share |

Managed Care prior authorization processes must not interfere with timely access to care.


Texas Medicaid clients age 0-20 are expected to have regular Texas Health Steps examinations, according to the periodicity schedule. This schedule is designed to follow national guidelines, to provide timely immunizations, and to ensure early detection of physical, emotional, sensory, and developmental problems. A mandated part of these examinations is regular developmental screening and periodic vison and hearing screening, in addition to the formal hearing evaluation and referral that is mandated for every Texas newborn. According to THSteps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents, subjective hearing screenings are indicated for infants and toddlers subsequent to a newborn hearing test.


Hearing Screenings and Evaluations

  • Formal evaluation of hearing, whether clinically indicated or not, is not a reason to delay access to a speech therapy evaluation or therapy.
  • If visit notes on the current up-to-date THSteps exam document a normal hearing screen, a referral for a specialist hearing evaluation must not be required for prior authorization of ST evaluation, re-evaluation, or treatment.
  • Authorizations for initial evaluations for speech therapy (ST) may not be delayed in order to perform hearing testing in excess of that provided at the child’s THSteps checkup. While a failed age appropriate hearing screening or concern expressed by a parent, a medical provider, a therapist, or others should result in a subsequent re-screening or evaluation of hearing, speech therapy may not be delayed. The speech therapy plan of care, however, must take into consideration the status of the child’s hearing, and MCOs may consider hearing status concerns on an individual basis when authorizing plans of care.
  • There appears to be no valid clinical reason for requiring a hearing test prior to authorizing a speech therapy evaluation for a child with dysphagia. This requirement has potential for delays or denials that might cause clients significant harm.
  • Requiring a hearing test with sedation in order for a child to access ST evaluation or re-evaluation is not recommended. Hearing testing requiring sedation has the potential for harm to the client, and is not
    an appropriate requirement for prior authorization of a speech therapy evaluation, particularly when it is not otherwise clinically indicated.
  • Requirements for specific hearing tests should be appropriate for the child. For example, provisions must be in place to account for instances in which a child’s disability or difficulty with compliance precludes cooperation with a pure tone audiometry test.

Developmental Screenings

  • MCOs may prior authorize initial evaluations and re-evaluations for physical, occupational, and speech therapies. However, they must not require additional physician visits or developmental screenings if the THSteps check-up is current and supports the need for an initial evaluation or re-evaluation as reflected in visit notes.
  • Prior authorization processes for initial evaluations, re-evaluations, and therapy services must include provisions to allow for extenuating circumstances such as staggered therapy authorizations, timeliness of access to pediatric audiologists, and other unique circumstances.
  • Nothing in the Texas Medicaid Provider Procedures Manual (TMPPM) vol. 2 Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook should be construed to mean that MCOs must require a developmental screening outside of that delivered during the THSteps check-up according to the periodicity schedule

Diagnosis Restrictions

  • Nothing in the Texas Medicaid Provider Procedures Manual (TMPPM) vol. 2 Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook should be construed to mean that MCOs may limit the provision of therapy services solely on the basis of the presence or absence of a particular diagnosis, including behavioral health diagnoses. As with all therapy services, therapy approved through Medicaid must meet medical necessity criteria as outlined in the TMPPM Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook.

Restrictions on Goals or Interventions of Therapies

  • Nothing in the Texas Medicaid Provider Procedures Manual (TMPPM) vol. 2 Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook should be construed to mean that MCOs may place blanket restrictions on cognitive or behavioral therapeutic interventions or goals. TMPPM Section 4 Therapy Services Overview of the TMPPM clearly defines functional goals. This definition is a description of the scope of the benefit:
  • Functional goals refer to a series of behaviors or skills that allow the client to achieve an outcome relevant to his/her health, safety, or independence within the context of everyday environments.
  • Functional goals must be specific to the client, objectively measurable within a specified time frame, attainable in relation to the client’s prognosis or developmental delay, relevant to client and family, and based on a medical need.

MCOs may use language from the TMPPM when creating policy guidance for their providers and members.


Clarification regarding the coordination of PT/OT/ST services between Medicaid MCOs and schools that participate in the School Health and Related Services (SHARS) program.


Nothing in the Texas Medicaid Provider Procedures Manual (TMPPM) vol. 2 Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook should be construed to mean that MCOs must obtain a client’s educational records, including records related to PT/OT/ST services provided at school under the School Health and Related Services (SHARS) program, when coordinating services.


Educational records are protected by the Family Educational Rights and Privacy Act (FERPA) and may be released only with a parent’s written consent. MCOs, therapy providers, and primary care physicians may request client records in order to coordinate client services. However, clients and families may not be compelled to provide FERPA-protected information. Approval of Medicaid therapy services provided by an MCO may not be made contingent upon review of FERPA-protected educational records.


As with all therapy services, therapy approved through Medicaid must meet medical necessity criteria as outlined in the TMPPM Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook.


Questions or comments may be directed to: MCDMedicalBenefitsPol@hhsc.state.tx.us


more Calendar

The upcoming calendar is currently empty.

Click here to view past events and photos »

Featured Jobs
Membership Software Powered by YourMembership  ::  Legal