- Dianna Watkins
- Jul 8, 2025
- 4 min read
Lots of changes lately to keep us on our toes....
CareSource will be requiring authorizations starting 7/10/2025 for PT/OT/SLPs again. Most authorizations are returning within 12 hours or less. To follow suit with Medicaid auths, we request the auth through the end of the month the POC expires. Some of these authorizations are being voided on GAMMIS for "auth not necessary".
If you see this, submit the following auth form via fax to obtain an authorization for that patient.
PSHP has been also processing and paying claims again. There was a brief interruption due to a system update that started around 6/10 and lasted until almost the end of June, rejecting for ordering/prescribing/referring provider missing or incorrect. It's best to resubmit claims back to Peachstate in most software to get them to process IF you don't see the claim pending online. Also make sure to run another A/R report to make sure all claims were processed at the end of this month.
Medicaid manual has been updated on GAMMIS for this quarter. The two changes listed were for clarifying Medicaid's definition of CPT codes 97550 and 96112/96113:
1001.14. Clarification on the use of CPT code 97550 - Use of this code must be documented in the plan of care with specific information on how and why it is medically necessary to provide caregiver training without the member present. CPT code 97550 should not be used for review of goals or review of the latest therapy session. This code should be specific training for a technique, procedure, equipment use, or care and programming for more complicated equipment. This code does not substitute for home program instruction and review. Documentation should reflect separate time and scheduling for this training outside of care of the member. (Rev. 07/2025)
1001.15. Clarification on the use of CPT code 96112 and 96113 – Use of CPT code 96112 goes beyond the scope of a typical evaluation by the individual professional. It includes standardized testing when done in its entirety but should not be used for portions of a standardized test or developmental tests for the purpose of screening only. Portions of a standardized test are allowed for the CIS requirement of standardized testing; however, portions of standardized testing will not be considered adequate to support use of 96112. (Rev. 07/2025) 1001.15.1. CPT code 96113 is an add-on code to allow additional time following the use of CPT code 96112. When requesting, 96113, you must also request 96112 on the same PA and it should be accompanied by significant documentation to support the need for both. (Rev. 07/2025)
Also note that in April 2025 Medicaid changed the timeline for all documentation for Children's Intervention
Maintain written documentation of all services provided to members for a minimum of 10 years after the date of service
Medicaid manual for ABA also have several changes this month that should be noted.
The cover sheet has been updated that should be used for all authorizations going forward.
Noted changes:
804.11. Behavior reduction line graphs tailored for the school setting, designed to comply with the specifications outlined in Appendix D. As part of the clinical review process, any behavioral interventions implemented in the school setting that were amended or modified during the previous authorization period due to insufficient progress must be clearly identified. These changes should be visually represented using phase change lines within data displays to demonstrate the effectiveness of the revised interventions. This visual documentation supports data-driven decision-making and ensures transparency in treatment adjustments.
803.5. Updated data collected during previous treatment authorizations (if not initial request). For continued treatment authorization (non-initial requests), updated data collected during the previous authorization period must be current and aligned with the most recent behavior assessment. For any new goals that were previously baselined but not yet introduced, probe data must be included. This data should reflect the member’s current performance and must not be more than two months older than the effective date of the requested prior authorization. This ensures that treatment planning is based on timely and relevant information.
804.10. Titration plan that includes a timeline when behavioral conditions qualify the fading out of school services when criteria for progress are established.
804.12. The most recent Individualized Education Plan (IEP), Individualized Family Support Plan (IFSP), and/or 504 plan should be included for members who attend a public school.
When school services are medically necessary, school plans should be accompanied with a treatment plan for services to also occur in either the home and/or clinic setting as treatment in the school setting is limited to the reduction of problem behavior that impede the member’s ability to engage in academic tasks and the teaching of functionally equivalent replacement behaviors. Exceptions to services occurring exclusively in the school environment will be evaluated on an individual basis and must be supported with clinical rationale.
Training of School Personnel: To promote consistent coordination of care, it is strongly encouraged that training of school personnel occurs in the presence of the parent or guardian, either virtually or in person. This collaborative approach ensures alignment across home and school environments. When additional school support is medically necessary, providers may request supplemental units of CPT code 97156. These requests should include clearly defined goals specific to the school setting, with a focus on training related to behavioral intervention procedures and the implementation of appropriate replacement behaviors.
Also remember for authorizations for ABA (from the manual:
Please allow up to 45 calendar days for the PA request to be reviewed and a decision to be rendered. Allow up to 10 calendar days for the reconsideration request to be reviewed and a decision rendered.
Please note that ALL PA’s for ALL Medicaid Members MUST be APPROVED prior to services being rendered. Any services rendered without an APPROVED PA or provided prior to the PA Effective date will not be authorized or eligible for reimbursement. Effective dates on existing PA’s cannot be made retro or backdated under ANY circumstance or for ANY reason. Members who are terminated and later reinstated with a retroactive eligibility date do NOT qualify for retroactive PAs. Members who are approved for Katie Beckett with a retroactive eligibility date do NOT qualify for a retroactive PA.
Providers may set the PA effective date for up to 30 days prior to the submission date.
