REVISED: Physical and Occupational Therapy Coverage for Adults in a Clinic Setting

REQUIREMENTS: - By July 31, 2026 (or upon implementation): Billing team must update the billing system to track and enforce the following limits for adult patients (21+ years): maximum 2 PT evaluations per state fiscal year, maximum 2 OT evaluations per state fiscal year, and maximum 12 combined OT/PT visits per state fiscal year. Implement limit monitoring via the Service Limit section (code 5109) once the audit becomes available in the system (notification via RA message will be sent). - Immediately: Update all CMS-1500 paper claim submissions to include Box 19 entry 'F' (indicating individuals ages 18+ receiving therapy services) and Box 17 entry with Specialist MCD ID who ordered services. If PCP is involved, submit a separate CMS-1500 per ON-025-24 instructions. - Before claims processing begins: Ensure billing software can identify when a member's therapy visit limit (12 visits) is exhausted and can generate appropriate denial messages for RA submission. - For extension of benefits requests: Establish process to submit requests within 90 calendar days of benefit-exhausted denial date, including Medical Assistance Remittance (RA), Status Report, clinical notes, and supporting documentation to AFMC using process type 126. Do not send the denied claim itself. - Train billing staff that services rendered by both OT and PT on the same day count as 2 separate visits against the 12-visit limit. - Consequence of non-compliance: Claims will be denied if limits are exceeded without proper prior authorization; extension requests submitted after 90 days will not be considered; technical denials will result from failure to provide requested documentation within specified timeframes.