Osteopathic Manipulation, Speech Therapy,
Physical/Occupational Therapy and Chiropractic Therapy Guidelines

Benefits for these services are subject to the following guidelines:

20 visits will be allowed per calendar year without certification. A maximum of 60 visits will be allowed each calendar year.

Treatments, which exceed 20 visits per calendar year, must be referred to Health Care Management Division (HCMD) and the appropriate professional consultant for review. Manipulative therapy performed by an osteopath or medical doctor is also subject to these guidelines.

Referral forms for chiropractic, physical medicine, occupational therapy and physical therapy must be completed and submitted to HCMD to initiate the certification process. The appropriate HCMD forms required to initiate the certification process can be found in the Provider drop down menu at the top of the web page titled Provider Forms or by clicking here. The professional consultant could subsequently request additional documentation from the provider.

The following information will be requested on the referral form:

• Diagnosis
• Summary of the case
• Approximate length of time treatments will be necessary
• Long/Short term goals

The following information may be requested by the professional consultant to support medical necessity:

• Complete treatment plan
• History and physical
• Assessment of the patient’s response to treatment as determined during the initial examination and reevaluation
• Progress notes