Molinalogo

Medicaid provides for medically necessary health services to eligible recipients for outpatient rehabilitation services such as physical therapy, occupational therapy, and/or speech therapy. Prior approval is required.

Make requests for outpatient rehabilitation services on form MAD 303; include supporting medical documentation. Your completed MAD 303 must include the following:

• Recipients name and Medicaid/SS number, birth date
• Provider name/provide Medicaid number (or NPI number with taxonomy code)
• Signature of therapist and diagnosis code
• MD signature only on the MAD 303 or a separate prescription for therapy
• If initial service, initial evaluation with measurable goals
• If continuing service, a re-evaluation with progress made on initial goals, with new goals if appropriate

Prior authorization requests must be submitted on an MAD 303 and include the following:

• Procedure code and procedure code description
• Units of service and frequency
• Time span (from/through dates)
• Total requested units

Example: 97110 Description: Therapeutic procedure

Prior authorization requests must be submitted on an MAD 303 and include the following:

• Therapy descriptor (PT, OT, or ST)
• Units of service and frequency
• Time span (from/through dates)
• Total requested units for the time span

Example: Physical Therapy

*Please note: MAD-MR 06-08 Departmental Memorandum is still to be followed regarding prior authorization is not needed for evaluation, testing, wound care, measurements, and other study procedures. For outpatient hospital rehabilitation services, revenue codes should be used for these procedures:

• 0424 Physical Therapy - evaluation or re-evaluation
• 0430 Occupational Therapy - evaluation or re-evaluation
• 0444 Speech Therapy - evaluation or re-evaluation (under 21 years of age)