Effective – July 1, 2016: The 2016 legislature has approved new therapy rules in IDAPA 16.03.09.
The Idaho MMIS Provider Handbook Speech, Language, and Hearing and Respiratory, Developmental, Rehab, Restorative Services Handbook has been revised to address and clarify the new rules. The Medical Care Unit has revised the Idaho Medicaid Therapy Service Documentation Coversheet, and the Medicaid Therapy Services Checklist.
House Bill 260, passed by the 2011 Idaho Legislature, directs the Department to limit physical, occupational, and speech therapy services covered by Medicaid so they align with annual Medicare caps.
For dates of service on or after January 1, 2012, the Department will limit therapy services to:
- $1,870 per calendar year for a combination of speech therapy services and physical therapy services.
- $1,870 per calendar year for occupational therapy services.
In order to be eligible for payment, the following documentation must be received when cap limitations are met for the calendar year and/or additional medically necessary services beyond these caps are needed.
- Therapy Coversheet
- Physician’s order
- Physician signed Plan of Care
- Current progress notes
To certify that any services provided beyond these limits are medically necessary, therapy providers must bill them in conjunction with a KX modifier on their claim form. Medicaid will deny claims for services beyond the cap that are not billed with a KX modifier or when the provider has not submitted current supporting documentation. Services that are not medically necessary, that do not require the skills of a professional therapist, or that are not supported by appropriate documentation will also be denied.
Information about how many therapy services a participant has used will be available in eligibility information at the Molina Health PAS portal, or by contacting Molina at (866) 686-4272. If you have questions about a denied claim contact a Molina Customer Service Representative to read you the memo on the denial.