Prior Authorization Therapy Attachment Completion (Page 4 of 8) in pdf

PRIOR AUTHORIZATION / THERAPY ATTACHMENT (PA/TA) COMPLETION INSTRUCTIONS

Page 4 of 8

F-11008A (07/12)

Element 17 — Check the appropriate box (on the PA/TA) and circle the appropriate form, if applicable:

The current Individualized Education Program (IEP) / Individualized Family Service Plan (IFSP) / Individual Program Plan

(IPP) is attached to this PA request.

The current IEP / IFSP / IPP is attached to PA number___________________.

There is no IEP / IFSP / IPP because ____________________________________.

Cotreatment with another therapy provider is within the plan of care.

Referenced report(s) is attached (list any report[s])__________________.

The IEP, IFSP, and IPP are reports used as follows:

• Individualized Education Plan — A written plan for a 3- to 21-year-old child who receives exceptional education services in school.

• Individualized Family Service Plan — A written plan for a 0- to 3-year-old child who receives therapy services through the Birth to

3 Program.

• Individualized Program Plan — A written active treatment plan for individuals who reside in an Intermediate Care Facility for the

Mentally Retarded.

Submission of the IEP, IFSP, and IPP with the PA request is required if the member is receiving services that require one of the

above written plans.

This section is included as a quick reference to remind providers to attach the necessary documentation materials to the PA request

and to remind providers to document cotreatment, if applicable, in their plan of care.

Cotreatment is when two therapy types provide their respective services to one member during the same treatment session. For

example, occupational therapists and physical therapists treat the member at the same time or occupational therapists and speech-

language pathologists treat the member at the same time. It is expected that the medical need for cotreatment be documented in

both providers’ plans of care and that both PA requests are submitted in the same envelope.

Other “referenced reports” may be swallow studies, discharge summaries, surgical reports, dietary reports, or psychology reports.

These reports should be submitted with the PA request when the information in those reports influenced the provider’s treatment

decision making and were referenced elsewhere in the PA request. Prior authorization requests submitted without the required or

referenced documentation attached to the PA request will be returned to the provider.

SECTION V — EVALUATION (COMPREHENSIVE RESULTS OF FORMAL / INFORMAL TESTS AND MEASUREMENTS THAT

PROVIDE A BASELINE FOR THE MEMBER’S FUNCTIONAL LIMITATIONS)

Element 18 — Attach a copy of the initial evaluation or the most recent evaluation or re-evaluation, or indicate with which

PA number this information was previously submitted.

Comprehensive initial evaluation attached. Date of initial comprehensive evaluation ___________.

Comprehensive initial evaluation submitted with PA number __________________.

Current re-evaluation attached. Date of most current evaluation or re-evaluation(s) ___________.

Current re-evaluation submitted with PA number __________________.

A copy of the comprehensive evaluation for the current episode of care (for the current problem being treated) must be included with

the PA request or submitted previously with another PA request, regardless of when treatment was initiated, and regardless of the

reimbursement source at the time of the comprehensive evaluation. An evaluation defining the member’s overall functional abilities

and limitations with baseline measurements, from which a plan of care is established, is necessary for the ForwardHealth consultant

to understand the member’s needs and the request.

The initial evaluation must:

(1) Establish a baseline for identified limitations — The evaluation should provide baseline measurements that establish a

performance (or ability) level, using units of objective measurement that can be consistently applied when reporting

subsequent status. It is very important to use consistent units of measurement throughout documentation or be able to

explain why the units of measurement changed.

Prior Authorization Therapy Attachment Completion Page 4

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