Prior Authorization Therapy Attachment Completion (Page 5 of 8) in pdf

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

Page 5 of 8

F-11008A (07/12)

Example 1: If the functional limitation is “unable to brush teeth,” the limiting factor may be due to strength, range of motion,

cognition, sensory processing, or equipment needs. The baseline should establish the status of identified limiting factors.

Such factors may include:

• Range of motion measurements in degrees.

• Eye-hand coordination as measured by a testing tool or units of speed and accuracy.

• Oral sensitivity as measured by an assessment tool or type of reaction to specific kinds of textures or temperatures at

specific oral cavity/teeth location.

• Grasp deficits including type of grasp and grip strength.

Later on, subsequent progress must be described using the same terms (e.g., grip strength increased by 2 pounds).

Example 2: If the functional limitation is “unable to sit long enough to engage in activities,” indicate “the member can short sit

for two minutes, unsupported, before losing his balance to the left.” Later on, progress can be documented in terms of time.

(2) Relate the functional limitations to an identified deficit — The evaluation must be comprehensive enough that another,

independent clinician would reasonably reach the same conclusion regarding the member’s functional limitation.

Example 1: The member is referred to therapy because “she doesn’t eat certain types of foods.” The evaluation should

clearly indicate the reason for not eating those certain foods. A deficit has not been identified if testing indicates the member

only eats Food “B.” Some deficit examples (for not eating a variety of foods) are: cleft palate, oral defensiveness, lip closure,

tongue mobility, an aversion to food, aspiration, attention span, member is G-tube fed and is, therefore, not hungry. The

identified deficit must be objectively measured and quantified (i.e., a baseline — see above).

Example 2: The member is referred to therapy because “he cannot go up and down stairs safely.” The evaluation should

clearly indicate the reasons for this functional limitation. A deficit has not been identified if the results of testing indicate the

member can only step up three inches. Strength, range of motion, balance, sensory processing, motivation, etc., must be

assessed and documented to identify the deficit causing the functional limitation (i.e., objectively tested, measured, and

quantified on the evaluation).

A re-evaluation is the process of performing selected tests and measures (after the initial evaluation) in the targeted

treatment area(s) to evaluate progress, functional ability, treatment effectiveness, and/or to modify or redirect intervention.

The re-evaluation must be submitted with the PA request whenever it is necessary to update the member’s

progress/condition. Using the same tests and measurements as used in the initial evaluation is essential to reviewing

status/progress. If new tests or measurements are used in the re-evaluation, explain why a different measurement tool was

used.

SECTION VI — PROGRESS

Element 19 — Describe progress in specific, measurable, objective, and functional terms (using

consistent units of measurement) that are related to the goals / limitations, since treatment was initiated

or last authorized.

(If this information is concisely written in other documentation prepared for the provider’s/therapist’s records, attach and write “see

attached” in the space provided.)

Document the goal or functional limitation in the left column on the PA/TA. Indicate the corresponding status for that goal or limitation

as of the previous PA request or since treatment was initiated (whichever is most recent) in the middle column on the PA/TA. Indicate

the corresponding status of that goal or limitation as of the date of the current PA request (do not use “a month ago” or “when last

seen” or “when last evaluated”) in the third column of the PA/TA. Progress relates to the established baseline, previous goals, and

identified limitations. Use the same tests and measurements as those units of measurement used in the baseline description.

The following information is necessary to evaluate the medical necessity of the PA request:

• Progress documented in specific, measurable, and objective terms.

• Use of words that are specific, measurable, or objective. (Words such as better, improved, calmer, happier, pleasant, less/more,

not as good, not as reliable, longer, more prolonged, and “goal not met” are not specific, measurable, or objective.) These do not

convey to the ForwardHealth consultant if, or how much, progress has been achieved. The following examples are specific,

measurable, and objective:

Example 1: Strength increased from POOR to FAIR, as determined with a Manual Muscle Test.

Example 2: Speech intelligibility improved from 30% to 70%, per standardized measurement.

Prior Authorization Therapy Attachment Completion Page 5

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