Medicaid Referral Requirement
ISHA is aware of the revised language in the Medicaid Handbook for Local Education Agencies that states "A referral by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under law is required for speech/language services. The referral must be updated annually and be maintained in the student’s health record." This has raised questions about the referral process for Medicaid billing for school speech-language pathologists. ISHA has been in contact with the Illinois Department of Healthcare and Family Services (HCFS) for clarification. HCFS is still researching the issues involved and plans to release a provider notice on the referral process. ISHA will also share this information as soon as we receive it.
Clarification Regarding Record Requirements for Therapy Services in Individualized Education Programs (IEPs)
To: Participating Local Education Agency Providers
Date: October 18, 2016
Re: Clarification Regarding Record Requirements for Therapy Services in Individualized Education Programs (IEPs)
This notice provides clarification on the documentation requirements Local Education Agencies (LEAs) must meet when seeking reimbursement for eligible expenditures related to therapy services.
Pursuant to federal regulation (42 CFR 440.110), physical therapy (PT) and occupational therapy (OT) must be prescribed/ordered, in writing, by a physician or other licensed practitioner of the healing arts acting within the scope of his or her practice under state law. The prescription/order for PT and OT must indicate specifications for the therapy services, including the diagnosis. Note that the Physical Therapy Practice Act (225 ILCS 75) and the Occupational Therapy Practice Act (225 ILCS 90) each limit the types of practitioners that can prescribe/order the respective services.
LEAs seeking reimbursement for services for individuals with speech and language disorders must obtain a written referral from a physician or other licensed practitioner of the healing arts acting within the scope of his or her practice under state law. The written referral specifies a need by making a recommendation for speech and language services, but the rendering practitioner, not the referring practitioner determines the diagnosis, frequency and duration of services to be provided.
Referrals for speech and language services can be made by a physician or other licensed practitioner of the healing arts acting within the scope of practice. Examples of other licensed practitioners that can refer speech services in the school setting include, but are not limited to, physician assistants, advanced practice nurses, clinical psychologists, speech-language pathologists or individuals with a Professional Educator License (PEL) endorsed in School Psychology or Speech Language Pathology. The referral of services provided in the school setting are subject to provisions of the Health Care Worker and Self-Referral Act (225 ILCS 47/1).
The prescription/order or referral is required prior to services being rendered and must be updated annually. The written prescription/order/referral must be included in the student’s file and be made available to the Department upon request. Neither the attendance sheet from the IEP meeting nor the signed IEP itself satisfies the requirement for a written prescription/order or referral.
Questions regarding this notice may be directed to the School-Based Health Services Program in the Bureau of Program and Policy Coordination at 217-782-3953.
Felicia F. Norwood