Library: Policy

317:30-5-291. Coverage by category

Revised 09-12-22

(a) Coverage. Payment is made to registered physical therapists as set forth in this Section.

(1) Children.  Initial therapy evaluations do not require prior authorization and must be provided by a fully licensed physical therapist. All therapy services following the initial evaluation must be prior authorized for continuation of service. Prior to the initial evaluation, the therapist must have on file a signed and dated prescription or referral for the therapy services from the member's physician or other licensed practitioner of the healing arts. The prescribing or referring provider must be able to provide, if requested, clinical documentation from the member's medical record that supports the medical necessity for the evaluation and referral.

(2) Adults.  There is no coverage for adults for services rendered by individually contracted providers. Coverage for adults is permitted in an outpatient hospital setting as described in Oklahoma Administrative Code (OAC) 317:30-5-42.1.

(3) Individuals eligible for Part B of Medicare.  Services provided to Medicare eligible recipients are filed directly with the fiscal agent.

(4) Alternative treatments for pain management. Refer to OAC 317:30-5-728.

(b) Payment rates.  All physical therapy services are reimbursed per the methodology described in the Oklahoma Medicaid State Plan.

(c) Procedure codes.  The appropriate procedure codes used for billing physical therapy services are found in the Physicians' Current Procedural Terminology (CPT) Coding Manual.