PT/OT/ST Service Authorization Tips

Date: 10/21/21

Heritage Health (Medicaid):

Effective November 1, 2021, Nebraska Total Care will update the PT/OT/ST authorization processes for Medicaid services as follows:

For Nebraska Total Care Medicaid members who are post-operative we will move to an Evaluation plus 12 sessions administrative auth model to expedite services and allow for immediate care

• Authorization may be called in by the provider, sent in via fax or via the provider portal with the required Medicaid OTR forms
• Must contain the diagnosis for the member as well as the date of surgery
• May be requested up to 30 days pre-op and 3 months post-op
• The date of the scheduled or completed procedure must be given over the phone or included in the requests sent in via fax or the portal

For pediatric members we will extend all pediatric auths to 6 month intervals

• The documentation requirements remain the same
• Providers are expected to be in compliance with the governmental regulations for completing re-evaluations and updates to their Plan of Care (POC). Decision on what meets medical necessity criteria will be based on the documentation submitted at the time of the request. You will not need to resubmit updated plans of care or orders during your authorization period unless there is a change of condition and more visits are needed

For members with chronic conditions

• Nebraska Total Care will administratively authorize up to two Evaluation plus 5 requests for the same diagnosis, for the same member, in each fiscal year

 

If you have questions, please contact Provider Relations.