August 01, 2022

Arizona Medicaid: Rehabilitative therapy services updates

Benefit limits and prior authorization requirements for rehabilitative therapy services

Review the benefit limits and prior authorization requirements for rehabilitative therapy services (physical, occupational and speech therapy) for UnitedHealthcare Community Plan of Arizona members in accordance with the AHCCCS Medical Policy Manual Ch 310-X.

Before providing rehabilitative therapy services to our members, please be sure to review the applicable prior authorization lists for Arizona Health Care Cost Containment System (AHCCCS) Complete Care (ACC), Developmentally Disabled (DD), and Long-Term Care (ALTCS).

Please note that prior authorization is required for all services rendered by out-of-network providers.

Rehabilitative therapy services for members younger than 21
Prior authorization is required as indicated on the prior authorization lists, except for services rendered to a CRS or Formerly CRS designated member, rendered in an in-network Multi-Specialty Interdisciplinary Clinic (MSIC). Services rendered to these members, in an in-network MSIC do not require prior authorization.

Prior authorization is not required and there are no benefit limits for inpatient physical, occupational or speech therapy services when rendered by an in-network provider.

Rehabilitative therapy services for members ages 21 and older
For ACC and DD members:

  • Prior authorization is not required for physical or occupational therapy when rendered by an in-network provider, but services are limited to the following:
    • 15 occupational and 15 physical therapy visits per benefit year (from Oct. 1 through Sept. 30) to restore a skill or level of function and maintain it
    • 15 occupational and 15 physical therapy visits per benefit year (from Oct. 1 through Sept. 30) to acquire a new skill or level of function and maintain it.
  • Prior authorization is not required for inpatient physical, occupational or speech therapy when rendered by an in-network provider.
  • Outpatient speech therapy is not a covered benefit.

For ALTCS members:

  • Prior authorization is required for the occupational and speech therapy codes listed on the prior authorization list
  • Outpatient therapy visits are limited to the following:
    • 15 physical therapy visits per benefit year (from Oct. 1 through Sept. 30) to restore a skill or level of function and maintain it
    • 15 physical therapy visits per benefit year (from Oct. 1 through Sept. 30) to acquire a new skill or level of function and maintain it.
  • Physical therapy conducted within a Nursing or Custodial Facility is considered as inpatient and not subjected to outpatient benefit limitations

For QMB Members:

  • Covered for unlimited visits when medically necessary for ACC and DD members
  • Copays are covered when medically necessary until Medicare benefit exhausts for ALTCS members

Questions?
If you have questions, please call Provider Services at 800 445 1638 for ACC and DD, or 800 293 3740 for ALTCS.

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