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Idaho Medicaid Provider HandbookTherapy ServicesTable of ContentsTherapy Services . 11.Important Contacts . 31.1.1.2.1.3.Gainwell Technologies. 3Provider Relations Consultants . 4Medicaid . 52.Provider Qualifications. 62.1. Home Health Agencies . 62.2. Hospitals . 72.3. Nursing Facilities. 82.4. Occupational Therapists . 92.4.1. References: Occupational Therapists . 92.5. Occupational Therapy Assistants . 112.5.1. References: Occupational Therapy Assistants . 112.6. Physical Therapists . 132.6.1. References: Physical Therapists . 132.7. Physical Therapy Assistants . 152.7.1. References: Physical Therapy Assistants. 152.8. Physician and Non-Physician Practitioners . 162.9. Rehabilitation Facilities . 172.10.School-based Services . 182.11.Speech-Language Pathologists . 192.11.1.References: Speech-Language Pathologists . 192.12.Speech-Language Pathology Assistants . 202.12.1.References: Speech-Language Pathology Assistants . 202.13.Therapy Aides and Supportive Personnel . 212.13.1.References: Therapy Aides and Supportive Personnel . 212.14.Therapy Students . 222.14.1.References: Therapy Students . 223.Eligible Participants . 233.1. References: Eligible Participants .3.1.1. State Regulations.3.2. Referrals.3.2.1. References: Referrals .3.3. Adults with Developmental Disabilities .3.3.1. References: Adults with Developmental Disabilities .3.4. Participants with Home Health .3.4.1. References: Participants with Home Health .23232424252526264.Covered Services and Limitations: General . 274.1. References: Covered Services and Limitations: General . 274.1.1. State Regulations. 27June 14, 2022i
Idaho Medicaid Provider HandbookTherapy Services4.2. Occupational Therapy .4.2.1. References: Occupational Therapy .4.3. Physical Therapy .4.3.1. References: Physical Therapy .4.4. Speech-Language Pathology .4.4.1. References: Speech-Language Pathology.4.5. Home Health .4.5.1. References: Home Health .4.6. Telehealth.4.6.1. References: Telehealth .4.7. Evaluations .4.7.1. References: Evaluations .4.7.2. Speech-Language Pathology Evaluations .4.8. Assessment.4.8.1. References: Assessment .4.9. Duplicate Services.4.9.1. References: Duplicate Services .4.10.Facility and Institution-Based Therapists .4.10.1.References: Facility and Institution-Based Therapists .4.11.Group Therapy .4.11.1.References: Group Therapy .4.12.Habilitative Therapy .4.13.Independent Therapists .4.13.1.References: Independent Therapists .4.14.Maintenance Therapy .4.14.1.References: Maintenance Therapy .4.15.Rehabilitative Therapy .4.16.Skilled Services .4.16.1.References: Skilled Services .4.17.Substitute Therapy Professional .4.18.Treatment Modalities .4.18.1.References: Treatment Modalities.4.19.Untimed Codes 747484949505151525.Covered Services and Limitations: Criteria . 535.1. Active Wound Care Management (OT/PT) .5.1.1. References: Active Wound Care Management .5.2. Acupuncture (Non-covered) .5.2.1. References: Acupuncture .5.3. Animal-Assisted Therapy (Non-covered) .5.3.1. References: Animal-Assisted Therapy .5.4. Aquatic Therapy (OT/PT) .5.4.1. References: Aquatic Therapy .5.4.2. Halliwick (Non-covered) .5.4.3. Watsu (Non-covered) .5.5. Art Therapy (Non-covered) .June 14, 20225455575758585959606162ii
Idaho Medicaid Provider HandbookTherapy Services5.5.1. References: Art Therapy .5.6. Athletic Trainer Services (Non-covered) .5.6.1. References: Athletic Trainer Services .5.7. Audiology Services (SLP) .5.8. Auditory Integration Therapy (Non-covered) .5.8.1. References: Auditory Integration Therapy.5.9. Auditory Rehabilitation (SLP) .5.9.1. References: Auditory Rehabilitation .5.10.Biofeedback (OT/PT) .5.10.1.References: Biofeedback .5.11.Cardiac Rehabilitation (OT/PT) .5.12.Cognitive Performance Testing (OT/PT/SLP) .5.12.1.References: Cognitive Performance Testing .5.13.Cognitive Rehabilitation (OT/SLP) .5.13.1.References: Cognitive Rehabilitation .5.14.Conditioning (Non-covered) .5.14.1.References: Conditioning .5.15.Craniosacral Therapy (Non-covered) .5.15.1.References: Craniosacral Therapy .5.16.Dry Needling (Non-covered) .5.16.1.References: Dry Needling .5.17.Feeding Therapy (OT/SLP) .5.17.1.References: Feeding Therapy .5.17.2.Dysphagia and Swallowing Disorders (OT/SLP) .5.17.3.Intensive Feeding Therapy (OT/SLP) .5.18.Hearing Screenings (SLP) .5.18.1.References: Hearing Screenings .5.19.Hippotherapy (Non-covered) .5.19.1.References: Hippotherapy .5.20.Interactive Metronome Therapy (Non-covered) .5.20.1.References: Interactive Metronome Therapy .5.21.Interdisciplinary Training (OT/PT/SLP) .5.21.1.References: Interdisciplinary Training .5.22.Massage (Non-covered) .5.22.1.References: Massage .5.23.Music Therapy (Non-covered) .5.23.1.References: Music Therapy .5.24.Oral Hygiene (OT/SLP) .5.25.Orthotic and Prosthetic Management and Training (OT/PT).5.25.1.References: Orthotic and Prosthetic Management and Training .5.26.Sensory Integration Therapy (Non-covered) .5.26.1.References: Sensory Integration Therapy .5.27.Speech Generating Device (SLP) .5.27.1.References: Speech Generating Device .5.28.Tests and Measurements (OT/PT) .5.28.1.References: Tests and Measurements .June 14, 7576777778788181828283838484858686878788899090iii
Idaho Medicaid Provider HandbookTherapy Services5.29.Therapeutic Procedures (OT/PT) .5.29.1.References: Therapeutic Procedures .5.30.Vision Therapy (OT/PT) .5.31.Vocational Programs (Non-covered) .5.31.1.References: Vocational Programs .5.32.Weight Management (Non-covered).5.32.1.References: Weight Management .5.33.Work Hardening (Non-covered) .5.33.1.References: Work Hardening .9191929393949495956.Utilization Management . 966.1. Post-Payment Review . 966.1.1. References: Post-Payment Review . 966.2. Prior Authorization . 986.2.1. References: Prior Authorization . 996.2.2. Prior Authorization Request Procedure . 1006.2.3. Prior Authorization Reconsiderations . 1016.2.4. Prior Authorization Appeals. 1027.Documentation Requirements . 1047.1. References: Documentation Requirements . 1047.1.1. State Regulations. 1047.2. Orders. 1057.2.1. References: Orders . 1057.2.2. Detailed Written Order . 1067.2.3. Preliminary Orders . 1077.2.4. Orders for Home Health . 1087.3. Plan of Care . 1097.3.1. References: Plan of Care . 1107.3.2. Elements . 1117.3.3. Plan of Care for Home Health . 1127.4. Progress Report . 1137.5. Treatment Notes . 1147.5.1. References: Treatment Notes . 1147.6. Discharge Note . 1157.6.1. References: Discharge Note. 1158.Reimbursement. 1168.1. References: Reimbursement . 1178.1.1. CMS Guidance . 1178.1.2. Idaho Medicaid Publications . 1178.1.3. State Regulations. 1188.2. Locum Tenens . 1198.2.1. References: Reimbursement . 1198.3. Misrepresentation of Services . 1208.3.1. References: Misrepresentation of Services . 1208.4. Reciprocal Billing. 121Appendix A.Occupational Therapy Services. 122June 14, 2022iv
Idaho Medicaid Provider HandbookTherapy Servicesa)References: Occupational Therapy Services . 125i) Idaho Medicaid Publications . 125Appendix B.Physical Therapy Services . 126a) References: Physical Therapy Services . 128i) Idaho Medicaid Publications . 128Appendix C.Speech-Language Pathologist Services . 129a) References: Speech-Language Pathologist Services . 130i) Idaho Medicaid Publications . 130Appendix D.Therapy Services, Provider Handbook Modifications . 131June 14, 2022v
Idaho Medicaid Provider HandbookTherapy ServicesTherapy ServicesThis chapter of the Idaho Medicaid Provider Handbook describes Medicaid-covered servicesprovided by: Home Health Agencies; Hospitals; Non-physician Practitioners; Nursing Facilities; Occupational therapists; Occupational therapy assistants; Physical therapists; Physical therapy assistants; Physicians; Rehabilitation facilities; School-based Services; and Speech-language pathologists.Services must be within the scope of practice, licensure and training of the provider renderingthem. This chapter of the handbook refers to occupational therapists, physical therapists, andspeech language pathologists collectively as therapist(s). It uses the term therapyprofessional(s) to refer to therapists, occupational and physical therapy assistants. The termnon-physician practitioner excludes pharmacists in this handbook. Services or situations thatonly apply to a specific provider type will be specified where applicable.Sections of the Idaho Medicaid Provider Handbook applicable in specific situations are listedthroughout the handbook for provider convenience. Handbook chapters which always applyto this provider type include the following: General Billing Instructions; General Information and Requirements for Providers; and Glossary.Handbooks can only be used properly in context. Providers must be familiar with thehandbooks that affect them and their services. The numbering in handbooks is also importantto make note of as subsections rely on the content of the sections above them.ExampleSection 1.2.3.a The Answer requires the reader to have also read Section 1,Section 1.2 and Section 1.2.3 to be able to properly apply Section 1.2.3.a.References are included throughout the handbook for provider and staff convenience. Not allapplicable references have been incorporated into the handbook. Not all references providedare equal in weight. Case Law: Includes references to court cases that established interpretations of lawthat states and providers would be required to follow. CMS Guidance: These references reflect various Centers for Medicare and MedicaidServices (CMS) publications that Idaho Medicaid reviewed in the formulation of theirpolicy. The publications themselves are not required to be followed for Idaho Medicaidservices. Federal Regulations: These references are regulations from the federal level thataffected policy development. Usually these include the Code of Federal Regulations,the Social Security Act and other statutes. They are required to be followed.June 14, 2022Page 1 of 131
Idaho Medicaid Provider Handbook Therapy ServicesIdaho Medicaid Publications: These are communications from Idaho Medicaid toproviders that were required to be followed when published. These are included in thehandbook for historical reference. The provider handbook supersedes othercommunications unless the documents are listed in the Department’s Rules, Statutes,and Policies webpage under policies in Medicaid’s department library.Idaho State Plan: The State Plan is the agreement between the State of Idaho and theCenters for Medicare and Medicaid Services on how the State will administer its medicalassistance program.Professional Organizations: These references reflect various publications ofprofessional organizations that Idaho Medicaid reviewed in the formulation of theirpolicy. Providers may or may not be required to follow these references, depending onthe individual reference and its application to a provider’s licensure and scope ofpractice.Scholarly Work: These references are publications that Idaho Medicaid reviewed in theformulation of their policy. The publications themselves are not required to be followedfor Idaho Medicaid services.State Regulations: These references are regulations from the state level that affectedpolicy development. They usually include statute and IDAPA. They are required to befollowed.June 14, 2022Page 2 of 131
Idaho Medicaid Provider HandbookTherapy Services1. Important ContactsThe Directory, Idaho Medicaid Provider Handbook contains a comprehensive list of contacts.The following contacts are presented here for provider convenience.1.1. Gainwell TechnologiesGainwell Technologies is Idaho Medicaid’s fiscal agent that handles all claims processing andcustomer service issues.Gainwell Technologies Contact InformationGainwell Technologies Provider ServicesP.O. Box 70082Boise, ID 83707Phone: 1 (888) 686-4272Fax: 1 (877) mThe Medicaid Automated Call Service (MACS) is available 24 hours a day, seven days aweek. Provider service representatives are available Monday through Friday, 7:00 A.M.7:00 P.M. MT.Provider EnrollmentP.O. Box 70082Boise, ID 83707Phone: 1 (866) 686-4272Fax: 1 (877) comTechnical ServicesPhone: 1 (866) 686-4272Fax: 1 (877) 517-2040IDEDISupport@gainwelltechnologies.comJune 14, 2022Page 3 of 131
Idaho Medicaid Provider HandbookTherapy Services1.2. Provider Relations ConsultantsGainwell Technologies Provider Relations Consultants help keep providers up-to-date onbilling changes required by program policy changes implemented by the Division of Medicaid.Provider Relations Consultants accomplish this by: Conducting provider workshops; Conducting live meetings for training; Visiting a provider’s site to conduct training; and Assisting providers with electronic claims submissionJune 14, 2022Page 4 of 131
Idaho Medicaid Provider HandbookTherapy Services1.3. MedicaidThe Medical Care Unit is Idaho Medicaid’s team that reviews prior authorizations andretrospective reviews for therapy services.Medical Care UnitPO Box 83720Boise, ID 83720-0009Phone 1 (866) 205-7403MedicalCareUnit@dhw.idaho.govThe status of a prior authorization request submitted to the Medical Care Unit may be checkedonline at the Gainwell Technologies portal under “Authorization Status”, using your NPI. Ifyou have questions on a Denial, click on the Notes, which will explain the reason for theDenial.June 14, 2022Page 5 of 131
Idaho Medicaid Provider HandbookTherapy Services2. Provider Qualifications2.1. Home Health AgenciesHome health agencies may employ or contract with physicians, non-physician practitioners(except pharmacists), occupational therapists, occupational therapy assistants, physicaltherapists, physical therapy assistants and speech-language pathologists to provide alloccupational or physical therapy services, or speech-language pathology services per thishandbook. Refer to the Home Health and Hospice Services, Idaho Medicaid Provider Handbookfor information on qualifications for home health agencies.June 14, 2022Page 6 of 131
Idaho Medicaid Provider HandbookTherapy Services2.2. HospitalsHospitals may employ or contract with physicians, non-physician practitioners (exceptpharmacists), occupational therapists, occupational therapy assistants, physical therapists,physical therapy assistants and speech-language pathologists to provide all occupational orphysical therapy services, or speech-language pathology services per this handbook. Refer tothe Hospital, Idaho Medicaid Provider Handbook for information on qualifications for hospitals.June 14, 2022Page 7 of 131
Idaho Medicaid Provider HandbookTherapy Services2.3. Nursing FacilitiesNursing facilities may employ or contract with physicians, non-physician practitioners (exceptpharmacists), occupational therapists, occupational therapy assistants, physical therapists,physical therapy assistants and speech-language pathologists to provide all occupational orphysical therapy services, or speech-language pathology services per this handbook. Refer tothe Nursing and Custodial Care Facilities, Idaho Medicaid Provider Handbook for informationon qualifications for nursing facilities.June 14, 2022Page 8 of 131
Idaho Medicaid Provider HandbookTherapy Services2.4. Occupational TherapistsOccupational therapists in any state are eligible to participate in the Idaho Medicaid Program.They must be licensed by the Idaho Division of Occupational and Professional Licenses andthe state where the services are performed. Occupational therapists must have a NationalProvider Identification (NPI). An occupational therapist must have one of the followingqualifications: Successfully graduated and completed an occupational therapist education programaccredited by the Accreditation Council for Occupational Therapy Education (ACOTE)of the American Occupational Therapy Association, Inc. (AOTA), or successororganizations of ACOTE. The therapist must be either eligible to take, or havesuccessfully completed, the entry-level certification examination for occupationaltherapists developed and administered by the National Board for Certification inOccupational Therapy, Inc. (NBCOT). Successfully completed an education program outside the United States accredited assubstantially equivalent to occupational therapist entry level education in the UnitedStates by one of the following:o The Accreditation Council for Occupational Therapy Education (ACOTE) or itssuccessor;o The World Federation of Occupational Therapists;o A credentialing body approved by the American Occupational TherapyAssociation; oro Successfully completed the entry level certification examination foroccupational therapists developed and administered by the National Board forCertification in Occupational Therapy, Inc. (NBCOT).A Medicare certificate is required for enrollment and the name on the certification must matchthe provider. However, this requirement can be waived for providers only serving pediatricpopulations without Medicare coverage. Occupational therapists enrolling as pediatric onlyproviders are not eligible for Medicaid reimbursement for services provided to olderparticipants or participants with Medicare and the provider may not bill those participants fortheir services.Occupational therapists are eligible to be ordering, prescribing, referring and renderingproviders as allowed in this handbook.Occupational therapists must enroll as an Idaho Medicaid provider prior to submitting claimsfor services. See General Information and Requirements for Providers, Idaho MedicaidProvider Handbook for more information on enrolling as an Idaho Medicaid provider.2.4.1.(a)References: Occupational TherapistsFederal RegulationsAcceptance of State Payment as Payment in Full, 42 CFR 447.15 (2013). GovernmentPrinting Office, Occupational Therapy.” 42 C.F.R. Sec. 440.110(b)(2) (2017). Government Printing .pdf.June 14, 2022Page 9 of 131
Idaho Medicaid Provider HandbookThe
Idaho Medicaid Provider Handbook Therapy Services June 14, 2022 Page 1 of 131 Therapy Services This chapter of the Idaho Medicaid Provider Handbook describes Medicaid-covered services
