Physical therapy/occupational therapy checklist

Initial PT/OT therapy request

Inpatient therapy does not require prior authorization.

To facilitate the approval process, be sure you have the following information ready before logging on to RadMD.com or calling the NIA Magellan Utilization Management staff:

Name, office phone number and fax number of referring provider
Member name and ID number
Requested therapy discipline (PT and/or OT)
Name of treating provider office or facility where the service will be performed, phone number and fax number
Date of the initial evaluation
Treating diagnosis, body region being treated and onset date
Surgery date and procedure performed (if applicable)
Brief medical history and any summary of previous therapy
Baseline evaluation—including current and prior functional status

Objective tests and measures appropriate to the discipline of therapy
Standardize test with raw score, standardized scores and interpretation
School programs, including frequency and goals (for habilitative services)
Documentation for home and community programs the patient is involved in (for habilitative services)
Treatment prognosis and rehab potential
Treatment plan including interventions planned
Specific functional goals that are measurable, sustainable and time-specific
Projected frequency and duration of treatment
Discharge plan

Subsequent therapy requests

Re-evaluations and treatment plans since the last authorization
Therapy treatment documentation since last authorization
Summary of patient status and updated discharge plan

Note: Clinical information must be documented in the therapy treatment record and/or other medical record documentation, such as diagnostic imaging or testing reports, physician referral documentation. Handwritten notes on cover sheets, telephone calls or other fax pages not reflected in therapy treatment record or other objective documents will be noted—“handwritten note on cover sheet (telephone call, etc.) without confirmation in treatment record”—but will not constitute actionable information for clinical decision making. Be prepared to upload or fax medical records supporting the required information on the checklist.

Medical necessity determinations are based on NIA Magellan Guidelines (available on RadMD.com) and Apollo Managed Care clinical guidelines—comprehensive, evidenced-based healthcare review criterion (available upon request).