Authorization

A Service Authorization is always required prior to providing the following services:

1. Analysis of a cochlear implant done by an SLP (92601 GN, 92602 GN, 92603 GN, 92604 GN)
2. Applying low frequency, non-contact, non-thermal ultrasound (97610) for wound treatment
3. Physical performance test to determine functional evaluation (97750). We do not cover functional capacity assessments for vocational or educational purposes.
4. Providing an augmentative communication device
5. Once the threshold has been met for audiology services, authorization must be obtained before providing services beyond the threshold

Authorization Criteria and Documentation

Documentation submitted with the authorization form should:

1. Be readable, photocopied material
2. Be arranged in chronological order
3. Match requested services
4. Include reasons why the skills of a PT are required

Send only requested documentation, not the entire file.

Initial Evaluation

Documentation matching requested services and demonstrating the reasons the skills of an OT, PT, or SLP is required, including the following:

1. Treatment diagnosis and date of onset, including any contraindications to treatment
2. Summary of previous therapy, including all evaluation or assessment reports or summary of initial findings signed by the therapist providing services
3. Current and prior functional status, including baseline evaluation and brief history indicating medical necessity
4. Documentation of when current function was lost
5. All tests performed and interpretation of results
6. Identified problems
7. Plan of care: Include all plans of care since services began.
8. Additional documentation may be requested for authorizations to establish medical necessity, including clarification of carry-over therapeutic interventions such as in-home programs, school programs (rehabilitative services provided as part of an IEP), employment, and other settings, such as the following:
   1. School programs, including frequency and goals. With signed parental consent, outpatient rehabilitative service providers are encouraged to coordinate therapy services with school therapists.
   2. Community and home programs.
   3. Treatment notes: 60 days if applicable.

PrimeWest Health will retain copies of the initial evaluation for future authorization requests.

Authorization for Ongoing Services

1. Re-evaluation, including summary of progress.
2. Plan of care, every 90 days. Send all plans of care since last authorization.
3. Treatment notes, with verification of units provided since last authorization.
4. The first time an authorization is requested, even if the service is already ongoing (e.g., for service beyond the threshold), you must include the documentation under Initial Evaluation.

Retro-Authorization

Provide all the information indicated under Initial Evaluation and Authorization for Ongoing Services.

Authorization for Therapy Groups

1. Description of the purpose of the group
2. Duration of each session
3. Specifics of medical necessity
4. Number of group sessions requested
5. All items under Initial Evaluation and Plan of Care  

Authorization Termination

PrimeWest Health will terminate reimbursement when services are discontinued by the referral source or when the member has:

1. Met the goals of the plan of care;
2. Developed behavioral or vocational problems that are not being addressed and that interfere with the ability to participate in therapy (particularly in pediatric cases);
3. Failed to comply with the requirements of participation;
4. Developed medical contraindications; or
5. Reached a plateau prior to meeting goals.

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