• 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

Maintenance Therapy

Discontinuing Maintenance

When there is an established HEP/PMP and the recipient’s response to treatment is predictable, the following examples of HEP/PMPs may not require the professional skills and expertise of a PT, OT, or SLP provider after the initial treatment and instruction:

• Active-assisted, active, and resisted exercises.
• Activities of daily living.
• Ambulation when level of assistance and/or assistive device has been determined.
• Aquatic exercises.
• Chest PT.
• Cognitive skills — orientation, attention span, problem solving, conceptualization, integration of learning.
• Coping skills.
• Exercises to promote overall fitness.
• Expressive language.
• Fluency (e.g., stuttering).
• Hot/cold treatments.
• Independent living skills.
• Language structure, content, or functions.
• Massage.
• Memory sequencing.
• Play activities that stimulate development/strength/range of motion/coordination.
• Positioning.
• Range of motion exercises.
• Rote, drill activities.
• Sensory integration.
• Standing table.
• Strengthening exercises.
• Stretching exercises.
• Unattended electrical stimulation.
• Voice quality.

The professional skills and expertise of a PT, OT, or SLP provider may be required to execute the recipient’s maintenance therapy services if there is documentation that the nursing personnel or caregivers routinely performed the HEP/PMP as prescribed, but the outcome was affected by one or more of the following:

• Complicating factors related to the recipient’s diagnosis.
• Risk to the recipient’s health or safety as identified by the PT, OT, or SLP provider’s reassessment of the HEP/PMP.
• Unforeseeable problems associated with the recipient’s functional abilities being maintained by other caregivers.

In these situations it may be necessary for a period of brief, intensive treatment (if the recipient’s status has regressed) prior to resuming a maintenance program. These situations may require a new PA request.

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