Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth	
	MassHealth
	Rehabilitation Center Bulletin 11
	December 2004

	TO:	Rehabilitation Centers Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director

	RE:	New Prior Authorization Policy for Rehabilitation Therapy Services

Changes in Policy	To simplify the administration of the MassHealth therapy benefit for 
for Certain Therapy 	providers and members, MassHealth is making changes in its 
Services	policies for physical therapy (PT), occupational therapy (OT), and speech and language therapy (ST) services delivered on an outpatient basis.  This bulletin describes these changes, which are effective for dates of service on and after January 1, 2005.  

PA Requirements	Increase in Number of Payable Visits Before PA Is Required
Effective January 1, 2005	MassHealth is increasing the number of medically necessary PT, OT, and ST visits that are payable by MassHealth within a rolling 12-month period before prior authorization (PA) is required.  The increase in visits is shown below.  
	
Number of Visits Payable by MassHealth within Rolling 12-Month Period Before PA Is Required 	
Before 01/01/05	On or After 01/01/05	
8 PT visits	20 PT visits	
8 OT visits	20 OT visits	
15 ST visits	35 ST visits

	Therapy Evaluations 
	MassHealth will no longer require PA for comprehensive evaluations, and MassHealth will not count them as part of the therapy visits that are payable without PA within a rolling 12-month period.  

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How to Request PA	MassHealth encourages providers to submit their requests for PA through its Web-based Automated Prior Authorization System (APAS) at www.masshealth-apas.com.  To receive more information about requesting PA using APAS, including training for and access to APAS, call 1-866-378-3789.
.  
	Information about how to request PA on paper can be found in Part 2 of 
	Subchapter 5 of your provider manual.  

	Whether submitting requests for PA using APAS or on paper, it is important to complete your request properly and attach the necessary documentation, to reduce the possibility of a deferral or denial of your request.  

PA requests must include a current prescription, a completed Request and Justification Form for Therapy Services (THP-2), and a copy of a current comprehensive evaluation and treatment plan.  Refer to Subchapter 6 of the Rehabilitation Center Manual for service codes and descriptions.  When requesting PA, estimate the amount of time required for each service, and request the number of time units accordingly.  

Counting Visits	Effective for dates of service on and after January 1, 2005, regardless of how many visits the member has had before January 1, 2005, MassHealth will count the first therapy visit occurring on or after January 1, 2005, as the first visit toward the 20 PT, 20 OT, or 35 ST medically necessary visits that are allowed within a rolling 12-month period without PA.  

	Exception:  If a member is receiving PT, OT, or ST under a PA that was issued before January 1, 2005, and the PA expires on or after January 1, 2005, MassHealth will begin counting visits in accordance with the revised policy described in this bulletin after the number of visits approved under the PA have been provided or after the PA expires, whichever comes first. 

	Example:  If a member is receiving PT under a PA that was approved by MassHealth on November 15, 2004, and the PA expires on February 15, 2005, the rolling 12-month period for counting therapy visits begins on the date of the first visit after all of the visits approved under that PA have been provided or on the first visit after February 15, 2005, whichever comes first.  If this member’s next PT visit is February 25, 2005, then the 12-month period in this example begins on February 25, 2005.  In this example, MassHealth will pay for a total of 20 medically necessary PT visits between February 25, 2005, and February 24, 2006, without PA.  

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Regulation Changes	MassHealth is using this bulletin to communicate these revisions as quickly as possible.  MassHealth will update its regulations as soon as possible to reflect the PA policy changes detailed in this bulletin.  

Questions	If you have any questions about the information in this bulletin, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.