OT/PT/Speech

Comprehensive IEP, Evaluation, and Prior Authorization Requirements for School-Based Therapy Medicaid Billing

Before therapy services may be billed, a current IEP referencing the required related therapy service must be in place, and once a referral is made, the IEP team must determine the need for evaluation and services. The Division of Elementary and Secondary Education (DESE) and its authorized educational institutions may conduct therapy evaluations for students ages three (3) through twenty-one (21) for educational purposes; evaluations completed in accordance with IEP guidelines are valid for three (3) years from the date of completion and may transfer with the student if the receiving institution provides written acceptance. A district may also accept a private evaluation conducted for non-educational purposes with written acknowledgement, allowing use of that evaluation for up to one (1) year from the original evaluation date, after which a full educational evaluation is required. Prior to Medicaid claiming, an annual referral from the student’s primary care physician is required using the DMS-640 Medicaid form, and when therapy services total ninety (90) minutes or more per week, the completed DMS-640 must be submitted to Atrezzo, via Acentra Health for prior authorization approval for an extension of benefits.

Useful Therapy Links

• Billing Manual - Therapy Files

• DMS-640 Form 

• DMS-640 MITS Completed Example (printable)

• PASSE Letter from DMS Director for Doctor to Sign DMS-640

• MITS Underperforming Formula Instructions

• Therapy Cost Per Unit

• Medicaid Therapy Contractor Guidelines

• Most Commonly Used ICD-10 Codes