Physical Medicine and Therapy Policy Update


As a reminder, for recipients age 21 and over, PT/OT/ST services performed in an outpatient setting must be prior-authorized by the QIO, KePRO.  At a minimum, physical therapy services must improve or restore physical functioning as well as prevent injury, impairment, functional limitation, and disability following disease, injury or loss of a body part.  Occupational therapy must prevent, improve or restore physical and/or cognitive impairment following disease or injury. Speech language pathology must improve or restore communication skills and/or swallowing skills following congenital or acquired disease or injury.

InterQual criteria for outpatient rehabilitation will be used to evaluate medical necessity.  The list of therapy codes that requires prior authorization is listed in Section 4 of the Physician, Laboratory, and other Medical Professionals and the Hospital Services provider manuals.  KePRO authorizes the initial evaluation and the first four weeks of therapy upon request.  At four weeks, a concurrent review is performed to re-evaluate the patient’s condition and response to treatment.  At that time the provider may request up to an additional eight weeks of therapy.

Requests for prior authorizations from KePRO may be submitted using one of the following methods:

KePRO Customer Service: 1-855-326-5219

KePRO Fax: 1-855-300-0082

If you have any questions regarding this policy, please contact the Provider Service Center at (888) 289-0709.  Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

Report Fraud