Can I appeal an outpatient therapy threshold prior authorization decision?


When a service provided beyond the thresholds is determined to be not medically necessary through prior authorization and/or pre-payment review of the claim, it is denied as a benefit category denial. No appeals can be submitted on prior authorization decisions, appeals can only be made on claims processed and denied for medical necessity. The resulting claim determination would be subject to the regular appeals process.

Outpatient therapy can be billed for occupational, physical and speech therapy rendered within the SNF.

• The individual therapist providing physical, occupational or speech therapies may not bill separately for services provided in the SNF.

• These services must not be billed during the same time frame as an inpatient claim.

• Outpatient services must be submitted on a separate claim from inpatient services.

• Outpatient therapy services should be billed with the following revenue codes:

o 0420 for physical therapy

o 0430 for occupational therapy

o 0440 for speech therapy

Outpatient Therapy

Type of bill (231-234)

Revenue codes (0420, 0430, 0440)