California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51336 - Specialized Rehabilitative Services in Skilled Nursing Facilities and Intermediate Care Facilities

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Specialized rehabilitative services shall be covered in accordance with the
					 standards of medical necessity as set forth in Section
					 51303(a). Such
					 service shall include the medically necessary continuation of treatment
					 services initiated in the hospital or short term intensive therapy expected to
					 produce recovery of function leading to either (1) a sustained higher level of
					 self care and discharge to home or (2) a lower level of care. Specialized
					 rehabilitation service shall be covered contingent upon compliance with the
					 following requirements:
(1) The services shall
					 be ordered by the beneficiary's attending physician. The physician's signed
					 order, specifying the care to be given, shall be on the beneficiary's chart. A
					 copy of the order shall be made available for departmental review upon
					 request;
(2) The services require
					 prior authorization by the Medi-Cal consultant for the district in which the
					 facility is located. The authorization request may be initiated by the
					 therapist;
(3) The authorization
					 request shall be accompanied by a treatment plan, signed by the attending
					 physician, which shall include the following:
(A) Principal and significant
					 diagnoses;
(B) Prognosis;
(C) Date of onset of illness or
					 injury;
(D) Specific type, number,
					 and frequency of services to be performed by each discipline;
(E) Therapeutic goals of the service provided
					 by each discipline and anticipated duration of treatment;
(F) Extent of and benefits or improvements
					 demonstrated by any previous provision of physical therapy, occupational
					 therapy, speech pathology or audiology services;
(4) Authorization for rehabilitative services
					 shall be contingent upon compliance with the following requirements:
(A) The direct and specific relationship of
					 the services to the written treatment plan prescribed by the physician after
					 necessary consultation with the qualified physical therapist, occupational
					 therapist, speech pathologist or audiologist;
(B) Complexity and sophistication of the
					 level of service, or condition of the beneficiary which requires the judgement,
					 knowledge and skills of a therapist;
(C) Provision of the services with the
					 expectation that the beneficiary will improve significantly in a reasonable,
					 and generally predictable, period of time; or in order to establish an
					 effective maintenance program for a specific disease state;
(D) Performance of the services by the
					 qualified therapist specified in (a)(4)(A) above;
(E) Consideration of the services, under
					 accepted standards of medical practice, to be a specific and effective
					 treatment for beneficiary's condition;
(F) Reasonableness and necessity of the
					 services for treatment of the beneficiary's condition.
(5) Professional therapy necessary to
					 establish or periodically reevaluate a palliative or maintenance program may be
					 authorized. Services under treatment programs not requiring the skills of a
					 qualified therapist shall not be separately payable or authorized.
(6) No more than 30 treatments shall be
					 authorized at any one time. Authorizations shall be valid for up to 120 days. A
					 request for reauthorization shall include a statement describing the
					 beneficiary's progress toward achieving the therapeutic goals included in the
					 treatment plan.