• A written referral from the patient’s primary care physician (PCP) requesting an evaluation for the services provided.
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  • A written prescription for the services provided, signed and dated by the PCP or physician specialist dated within 12 months of the dates of service.
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  • All evaluations that support the medical necessity of the services provided.
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  • A treatment plan or plan of care (POC) for the prescribed therapy developed and signed by providers credentialed and licensed in the prescribed therapy or by a physician. 
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  • The plan must include goals that are functional, measurable and specific for each individual client.
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  • When applicable, an Individualized Family Service Plan (IFSP), Individual Program Plan (IPP) or Individual Educational Plan (IEP) is required.
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  • For an IEP, pages one (1) and two (2), the Goals and Objectives page (pertinent to the therapy requested) and the Signature Page of the IEP are all that are normally required for verification as review documentation.

           Note: For SpedTrack or similar software, please submit

  •                 All goals and objectives for the type of therapy under review

  •                 Schedule of Services

  •                 Signature page

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  • For the specific time frame of the claim being review, a description of specific therapy service(s) provided with date, actual time service(s) were rendered, and the name and title of the individual providing the service(s) is required.
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  • All therapy evaluation reports and dated progress notes describing the beneficiary’s progress signed by the individual providing the service(s) and any related correspondence.
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  • If the patient is no longer receiving services, copy of discharge notes and a summary are required.
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