Ga. Medicaid Part II Policies & Procedures for Hospital Services § 909

Rehabilitation as defined by federal regulation is not covered in the Hospital program. However, short-term rehabilitation services, i.e., Physical therapy, Occupational therapy and Speech therapy are

covered immediately following and in treatment of acute illness, injury or impairment when the

conditions listed below are met.

909.1. Services must be furnished under a written treatment plan established and signed and

dated by the Physician, NP or PA. This plan must identify the rehabilitation potential, set

realistic goals and measure progress. The plan must contain the type of modalities and

procedures that will be used, frequency of visits, estimated duration, diagnosis, functional

goals and recovery potential.

909.2. The physician must initially certify the plan of care (POC). The initial plan of care can

cover up to 3 calendar months or 12 weeks. Treatment units for 1 discipline per PA to

cover up to 3 calendar months can be submitted with each request. Prior authorizations

will only accept 3 calendar months and 1 discipline modifier. Any requests beyond the 3

calendar months will require an updated plan of care with recertification by the physician,

NP or PA and must be submitted in a new prior authorization request. Recertification

must include an estimate of how much longer the service will be needed and the diagnosis

and date of onset of the acute illness, injury or impairment that is being treated. All

requests will be reviewed for medical necessity and acuity.

909.3. The services must be of such a level of complexity and sophistication, or the member’s

condition must be such that the services required can be safely and effectively

performed only by or under the supervision of a qualified therapist in a hospital based

setting versus a community-based setting

909.4. There must be an expectation that the patient’s condition will improve significantly in a

reasonable and generally predictable period of time, or the services must be necessary

to the establishment of a safe and effective maintenance program required in connection

with a specific disease state.

909.5. The amount, frequency and duration of the services must be reasonable under accepted

standards of practice.

909.6. Physical therapy, occupational therapy, and speech therapy billed to the Division by the

individual practitioner are not covered in the Hospital program.