Kaiser Permanente Northwest (outpatient PT, OT, ST) pediatric speech and OT coverage: limits and referrals
By Javier Alvarez · Updated · 1 min read
1 row: Kaiser Permanente Northwest. Public policy, not the member's benefits.
Kaiser Permanente Northwest (outpatient PT, OT, ST)
UR 43 medical necessity criteria, KPNW Region · OR, WA
| Where it applies | Outpatient physical, occupational and speech therapy are medically necessary when criteria are met, including a licensed provider, a written plan of care with measurable goals, and no duplication of services in an IEP or ISP. The criteria apply to commercial and Medicare members with a rehabilitation or habilitation benefit. [1] |
|---|---|
| Diagnoses | For pediatric members, therapy requires a score below the 16th percentile (1.0 SD below the mean) on a standardized test with clinician-observed performance. For pediatric articulation disorder, the speech-language pathologist must find the deficits are not expected to improve with normal maturation. [1] |
| Visit limits | For pediatric members, retesting with the same norm-referenced tool is required annually for chronic or developmental conditions. Therapy is no longer medically necessary if a child scores at or less than 1.0 SD below the mean. A new evaluation is allowed no sooner than 3 months after the end of the prior episode unless the condition changed significantly. [1] |
| Referral | The member must be referred by an examining physician, physician assistant or nurse practitioner. A referral to a provider outside Kaiser or outside the plan service area must be authorized by the Regional Referral Center. [1] |
| Also | Not covered: maintenance therapy for chronic conditions (except Washington members with a neurodevelopmental condition), drills and exercises after medically necessary therapy ends, instruction of a secondary language, and self-correcting disorders such as natural dysfluency or articulation errors. [1] |
What Kaiser Permanente Northwest (outpatient PT, OT, ST)'s documents say
The table above has every field we found for Kaiser Permanente Northwest (outpatient PT, OT, ST), with numbered sources. In short:
- Visit limits. For pediatric members, retesting with the same norm-referenced tool is required annually for chronic or developmental conditions. Therapy is no longer medically necessary if a child scores at or less than 1.0 SD below the mean. A new evaluation is allowed no sooner than 3 months after the end of the prior episode unless the condition changed significantly.
- Where it applies. Outpatient physical, occupational and speech therapy are medically necessary when criteria are met, including a licensed provider, a written plan of care with measurable goals, and no duplication of services in an IEP or ISP. The criteria apply to commercial and Medicare members with a rehabilitation or habilitation benefit.
Pediatric speech and OT coverage at other national payers
Aetna (commercial), UnitedHealthcare (commercial and individual exchange), Anthem home-setting therapy and TRICARE (speech therapy and occupational therapy).
Check Kaiser Permanente Northwest (outpatient PT, OT, ST)'s claim against the row
Before the claim goes out, compare it with the row above: the evaluation and treatment codes are ones the policy lists, the plan of care and any prior authorization cover the date, and the visit count fits the limit. The pediatric speech and OT table compares Kaiser Permanente Northwest with every other payer we checked.