• Certification and Ongoing Responsibilities
  • Introduction
  • Other Facilities
  • Responsibilities
  • Supervision Requirements
    • Introduction
    • Declaration of Supervision
    • Supervision Waiver
  • Durable Medical Equipment and Disposable Medical Supplies
• Provider Communication
  • Introduction
  • Coordination with School-Based Services Providers
  • Coordination with County Birth to 3 Programs
  • Therapy Services for Children Brochure
  • Guide to Obtaining Augmentative Communication Devices and Accessories
  • Directory of Used Medical Equipment
• Documentation Requirements
  • Introduction
  • Prescriptions
  • Evaluations
  • Plan of Care
  • Daily Entries
• Services and Requirements
  • Introduction
  • Initial Spell of Illness
  • Daily Limitations
  • Duplicate Services
  • Evaluations
  • Group Therapy
  • Natural Environments
  • Durable Medical Equipment and Disposable Medical Supplies
  • HealthCheck "Other Services"
  • Services Not Separately Reimbursable
  • Reimbursement Not Available
• Codes
  • Procedure Codes
    • Introduction
    • Unit of Service
  • Modifiers
  • Place of Service Codes
  • Diagnosis Codes
• Prior Authorization
  • Introduction
  • Prior Authorization Forms and Attachments
  • Medical Necessity
    • Introduction
    • Relationship of Medical Necessity to Clinical Practice Principles
  • Flexibility of Approved Services
    • Introduction
    • Plan of Care Must Reflect Flexibility of Approved Services
    • Duration of Approved Services
    • Coordinating Multiple Prior Authorization Requests
• Requesting Extension of Therapy, Maintenance Therapy, and Services That Always Require Prior Authorization
  • Introduction
  • Approval Criteria
  • Extension of Therapy
  • Maintenance Therapy
    • Introduction
    • Direct Maintenance
    • Monitoring Maintenance
    • Discontinuing Maintenance
  • Services That Always Require Prior Authorization
    • Introduction
    • Cotreatment
    • Dual Treatment
    • Unlisted Procedure Codes
    • Decubitus Ulcers
• Requesting Spell of Illness
  • Introduction
  • Maximum Allowable Treatment Days
    • Introduction
    • Unused Treatment Days
• Extension of Therapy vs. Spell of Illness
• Requesting Services for Birth to 3 Participants
  • Introduction
  • Situations That Do Not Qualify for Birth to 3
• Requesting Amendments
  • Introduction
  • Approval Criteria
  • Reasons for Denial
• Claims
  • Introduction
  • 837 Health Care Claim: Professional
  • CMS 1500
  • Provider Numbers
    • Individual Providers
    • Groups, Clinics, and Nursing Homes
    • Rehabilitation Agencies
    • Hospitals
  • Referring Provider
  • Evaluations
  • Services Provided Beyond Daily Limits
  • Unlisted Procedure Codes
  • Multiple Services During One Session
  • Submitting Claims for Birth to 3 Services
• Reimbursement
  • Maximum Allowable Fees
  • Reimbursement Methods
    • Introduction
    • Natural Environment Enhanced Reimbursement
  • Copayment
    • Introduction
    • Annual Copayment Maximum
• Appendix
• PDF

Requesting Extension of Therapy, Maintenance Therapy, and Services That Always Require Prior Authorization

Approval Criteria

Comprehensive information about the recipient helps to establish the functional potential of the recipient and forms the basis for determining whether the recipient will benefit from the requested services. No single factor, such as diagnosis or age of the recipient, will result in automatic approval or denial of a PA request for extension of therapy services, maintenance therapy services, or services that always require PA.

It is essential that documentation is complete, accurate, and specific to the recipient’s current condition and needs. Providers are required to submit the following when submitting the PA/TA (fillable PDF, 134 KB):

• A written report of the recipient’s evaluation. Refer to the Documentation Requirements chapter of this handbook for information about evaluation reports.
• An individualized plan of care (POC) if not documented on the PA/TA. Refer to the Documentation Requirements chapter of this handbook for more information about the POC.
• A copy of the Individualized Family Service Plan (IFSP) if the recipient is a Birth to 3 participant and the services are being requested with the PA/TA.* Refer to the Requesting Services for Birth to 3 Participants chapter of this handbook for information about submitting the IFSP with the PA/TA.
• A copy of the Individualized Education Plan (IEP) if the recipient is a school-age child.*
• A copy of the Interdisciplinary Program Plan (IPP) if the recipient is in a residential or day facility for the developmentally disabled.* The IPP must document coordination and integration of the active treatment and medical care plan of the recipient.

Refer to Appendix 17 of this handbook for additional approval criteria for extension of therapy services, maintenance therapy services, and services that always require PA.

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