For Professionals

Providers May Require Authorization for Therapy Services

Prior-authorization requirements under Georgia Healthy Families and certain Care Management Organizations may impact the rehabilitative services your patients are able to receive from Children’s. Please review the following information before making a referral:

Georgia Healthy Families 

Rules, regulations and requirements from the Department of Community Health (DCH) may impact the way your Medicaid patients receive rehabilitative services. Children’s is working to help ensure your patients’ rehabilitative care is continued appropriately for their condition.

The Medicaid program requires:

  • Preauthorization for therapy services for children who are covered by Medicaid. They will only authorize treatment at Children’s for patients who have an acute injury, illness or impairment and/or require a specialty service. Specialty services include, but are not limited to, whirlpool, casting and splinting services. This will impact children with SSI and Deeming Waiver. Both a physician-signed Letter of Medical Necessity (LOMN) and an updated order are required for treatment.
  • Children with chronic conditions and impairments must be seen through the Children’s Intervention Services (CIS) program.

For prior authorization to be obtained from Medicaid, the Outpatient Rehabilitation Clinical Review Team must obtain clinical information from the referring physician that clearly identifies an acute condition requiring rehab services or the specialty service needed. 

  • Fax any clinical information on the prescription to 404-785-7113. This helps facilitate approvals. 
  • If the problem is acute, we obtain the prior authorization. Then, we will schedule your patient for treatment. 

To serve your patients in a timely manner we need your help in ensuring the orders are returned to us promptly.  We also provide case management services, including finding CIS providers for the patient family.

In addition, the Medicaid program:

  • May notify Children’s that your patient must be transitioned to a CIS provider—if this happens, we will inform the patient family of the need for this transition.
  • As of April 2014, Medicaid requires physicians to register as a participating/billing provider (PAR) or ordering, referring provider (OPR).

To find out more about the Medicaid program, visit Provider Information at www.mmis.georgia.gov or contact the Division of Medical Assistance at 800-766-4456 or the Children’s Outpatient Rehab Case Management Team at 404-785-8758.

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WellCare

Please be aware that in order to obtain authorization for therapy services for patients in settings other than Babies Can’t Wait or the public school system, WellCare is requiring three documents:

  • The Ancillary Service Authorization Request form
  • A plan of care or written service plan
  • The Provider Attestation form—for new patients, this form needs to be completed by the referring physician. For existing patients, the therapist may complete this statement.

Children’s will work to complete these forms for all requests for reauthorization of treatment. We will fax any information to your office requesting further assistance if needed.

When referring for audiology evaluation, please indicate in the prescription if testing was attempted in the PCP office and when further testing is being requested.

Thank you for your ongoing cooperation with this process. Children’s is doing everything we can to continue to treat your patients. If you have further questions, please contact the WellCare of Georgia at 1-866-231-1821.

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