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Coverage criteria policies

Speech Therapy – Rehabilitative – Minnesota Health Care Programs

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Rehabilitative Therapy

Prior authorization is not required for outpatient rehabilitation and therapeutic services, including speech therapy.

Habilitative Therapy

Habilitative Therapy is outside the scope of this policy. Please see related content at right for link to policy.

Feeding Therapy

Feeding/ oral function therapy for children is outside the scope of this policy.  Please see related content at right for link to policy.

Coverage

Rehabilitative speech therapy is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

To be covered as a rehabilitation and therapeutic service, speech-language pathology and audiology services require written referral by a physician or other licensed practitioner of the healing arts, or in the case of a long-term care facility resident, on the written order of a physician.

Services must require the skills of at least one of the following:

  • A speech-language pathologist
  • An audiologist
  • A person completing the clinical fellowship year required for certification as a speech-language pathologist
  • A person completing the clinical fellowship year required for certification as an audiologist and working under the supervision of an audiologist

A Plan of Care must specify treatment. The recipient's attending physician, or other licensed practitioner of the healing arts, must review and revise as medically necessary the plan of care at least once every 90 days.

The physician or other licensed practitioner of the healing arts as defined in this section must expect the recipient’s functional status to progress toward or achieve the objectives in the recipient's plan of care within a 90-day period.

Providers must comply and adhere to all DHS provider manual rules regarding plan of care and documentation.

Indications that are not covered

  1. Speech-language or audiology services provided without a written referral from a physician or other licensed practitioner of the healing arts
  2. Services for speech-language pathology or audiology services provided by a person whose temporary license has expired
  3. Services for activities of daily living when performed by the therapist, therapy assistant or therapy aide
  4. Specialized maintenance therapy for MHCP recipients age 21 and over
  5. Art and craft activities for the purpose of recreation
  6. Services that are not:
    1. Medically necessary
    2. Documented in the recipient's health care record
    3. Part of the recipient's plan of care
    4. Designed to improve or maintain the functional status of a recipient with a physical impairment or a cognitive or psychological deficit
  7. Services specified in a plan of care that is not reviewed and revised as medically necessary by the recipient’s attending physician or practitioner of the healing arts as defined in this section
  8. Services by more than one provider of the same type for the same diagnosis unless the school district provides the service as specified in the recipient's IEP
  9. Vocational or educational services, including functional capacity evaluations, except as provided under IEP (individualized education program)-related services.
  10. Services provided by a therapy aide or therapy student
  11. Psychosocial services
  12. Record keeping, documentation and travel time (the transport and waiting time of a recipient to and from therapy sessions)
  13. Services provided by a rehabilitation agency that take place in a sheltered workshop, Day Training and Habilitation center (DT&H), Day Activity Center (DAC), or a residential or group home that is an affiliate of the rehabilitation agency

Definitions

Functional status: The ability to carry out the tasks associated with daily living.

Practitioner of the Healing Arts: For the purposes of this section, practitioner of the healing arts includes any person who engages in, or holds out to the public as being engaged in, the practice of medicine or surgery, the practice of osteopathy, or other practitioner of the healing arts whose scope of practice under state law includes diagnosis of disease or health condition and prescribing treatment; for example, physician assistant, nurse practitioner, podiatrist, oral surgeon, dentist, optometrist.

Rehabilitation and Therapeutic Services: Restorative therapy, specialized maintenance therapy and rehabilitation nursing services.

Restorative therapy: A health service specified in the recipient's plan of care, ordered by a physician or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law, who has certified that the service is designated to restore the recipient's functional status to a level consistent with the recipient’s physical or mental limitations.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual: Rehabilitation Therapy Services. Revised 09-26-2012
  2. Minnesota Health Care Programs (MHCP) Provider Manual: Rehabilitation Services. Revised 08-03-2016

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Policy activity

  • 01/01/1998 - Date of origin
  • 11/01/2017 - Effective date
Review date
  • 11/2017
Revision date
  • 12/14/2016

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