Verifying Remaining Therapy Service Units

1. Log in to the Provider Web Portal.
2. Click the Eligibility tab.
   
    
3. Click the Eligibility Verification link.
   
    
4. Enter search criteria, then click "Submit."
   

5. Check the member's available units of physical/occupational therapy (PT/OT) services under the Limit Details section by clicking “Expand All” at the top of the screen.

   
    

   The remaining benefit amount is calculated by counting all the paid PT/OT units of service that a member has incurred in the previous rolling 365 days. Once the soft limit of 48 units has been reached, an approved Prior Authorization Request (PAR) is required to exceed it.

   The counting function will calculate PT/OT units regardless of whether they were paid with a PAR on file. This means that after a PAR for PT/OT is exhausted, members will not automatically have another 48 units of PT/OT available without a PAR. A full 365 days must elapse before the member has another 48 units of PT/OT available without requiring a PAR.

   Refer to the Benefit Limitation Frequently Asked Questions, located on the Outpatient PT/OT Benefits web page, for more information.

The Department will reimburse Speech Therapy services for Title XIX (TXIX) and Alternative Benefit Plan (ABP) members when the following conditions are met:

• A speech therapy code is billed on a Professional  (CMS-1500) Fee for Service (FFS) Claim 
• The billing provider is allowed to bill speech therapy codes.
• The rendering provider is allowed to perform speech therapy services.
• Rehabilitative is identified with modifiers GN, 97 – no age restrictions.
• Habilitative is identified with modifiers GN, 96 – (ages 0-20 for TXIX)
• Early Intervention is identified with modifiers GN, TL - (ages 0-3 for TXIX)
• The limit has not been met or there is a Prior Authorization that allows for additional services beyond the limit.
  • TXIX (ages 0 -20) 12 sessions combined for habilitative/rehabilitative/Early Intervention. 
  • TXIX (ages 21 and over) 12 sessions for rehabilitative only.
  • ABP 12 sessions of habilitative (no age restrictions)
  • ABP 12 sessions of rehabilitative. (No age restrictions)

The allowed billing provider is reimbursed for covered speech therapy services so that TXIX and ABP members can receive Speech Therapy service within the limit and beyond the limit with prior authorization.

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