NCTracks
Update on Outpatient Specialized Therapy Claims and PA
Effective May 1, 2016, Outpatient Specialized Therapy claims will deny when the required prior authorization (PA) has been denied or has expired, or the authorized units have been used. This is applicable to Medicaid and NC Health Choice claims adjudicated on or after May 1, 2016. No reprocessing will occur as a result of this new implementation.
Providers will begin to see new EOB 01807 (PRIOR AUTHORIZATION FOR OUTPATIENT SPECIALIZED THERAPY SERVICES IS MISSING OR EXHAUSTED) for institutional (837I/UB-04) and professional claims (837P/CMS-1500 format) when no PA is found during the matching process between a claim and PA, which takes place during claim adjudication. If the units on the claim exceed the number of available units on the PA, the claim will deny for this EOB; no cutbacks are applied. This EOB is also applied when no valid PA is on file.
Note: Inpatient services and services provided by Local Education Agencies (billing taxonomy 251300000X) are not required to obtain PA for specialized therapies and do not bill with a rendering provider.
The NCTracks system will search, compare and confirm that the information on the PA and claim are valid, accurate and are a match. During this process, it will compare the provider taxonomy code to the procedure code to ensure that the procedure code/revenue code is a service for the provider type.
Outpatient Specialized Therapy providers can only bill for therapy services. These providers are identified by taxonomy codes. (See list below.) These providers will be the rendering provider on professional claims and the attending provider on outpatient institutional claims.
- 231H00000X-Audiologist
- 225X00000X-Occupational Therapist
- 225100000X-Physical Therapist
- 227900000X-Respiratory Therapist, Registered
- 235Z00000X-Speech-Language Pathologist
Institutional Claims:
Two new EOBs for claim adjudication have been created for this new implementation that is applicable only to institutional claims when the attending provider taxonomy is a Specialized Therapy provider based on the taxonomy codes above.
- EOB 1790 (MAX SUBMITTED UNITS FOR REVENUE CODES FOR OUTPATIENT SPECIALIZED THERAPY IS ONE) is applied when revenue codes 0420, 0424, 0430, 0434, 0440 and 0444 are billed with units greater than one.
- EOB 01827 (SPECIALIZED THERAPY PROVIDERS MAY ONLY RENDER PROVIDER TYPE SPECIFIC THERAPY SERVICES) is applied when the provider has billed a service that is not a specialized therapy service.
For further information regarding guidelines and requirements, please refer to clinical coverage policies for Specialized Therapies on the N.C. Division of Medical Assistance website.