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Occupational Therapy Criteria

Approved:  8/06
Reviewed:  2/07, 2/08, 3/10, 2/11, 1/12, 1/13, 3/14, 2/15, 1/16, 1/17
Revised:  1/09

 

Occupational therapy involves the use of purposeful activities to help people regain performance skills lost through injury or illness.   

Occupational therapy is covered when one of the following criteria is met and occupational therapy is prescribed by an appropriate health care provider to improve or restore lost or impaired performance skills.

  1. To provide task-oriented therapeutic activities designed to significantly improve, develop or restore physical functions lost or impaired as a result of disease or injury. 
  2. To learn or relearn daily living skills or compensatory techniques to improve the level of independence in activities of daily living 
  3. To evaluate durable medical equipment requirements.

Additionally, the occupational therapy care plan is required to contain documentation of the medical necessity of such treatment as evidenced by:

  1. Occupational therapy is provided in accordance with an ongoing written plan of care. The health care provider assists in the determination of appropriate adaptive equipment when functional disability is present and in the education needed to utilize the equipment.
  2. Sufficient information is included in the plan of care to determine the medical necessity of treatment.
  3. The plan of care is signed by the attending physician and licensed occupational therapist.
  4. The occupational therapy plan of care includes:
    1. The date of onset or exacerbation of the disorder/diagnosis
    2. Specific statements of type and long term goals
    3. Documentation that is quantitative and objective
    4. A reasonable estimate of when the goals will be reached
    5. The specific treatment techniques and/or exercised to be used in treatment
    6. The frequency and duration of treatment

ConnectCare

Utilization Management

ConnectCare's Utilization Management Staff is available to address questions and issues related to case management and utilization by using the telephone or fax numbers listed below.

ConnectCare Medical Management
4000 Wellness Drive
Midland, MI 48670
Toll free: 888-646-2429
Local: 989-839-1613
Fax: 989-839-1679
 
Hours of Operation
8:00 a.m. - 12:00 p.m.
1:00 p.m. - 5:00 p.m.
Monday - Friday (Eastern Time)

After normal business hours, inbound communications and information may be relayed via fax, confidential voice mail or electronic mail. All precertification requests and/or communications received after normal business hours are returned on the next business day and communications received after midnight on Monday through Friday are responded to on the same business day.

Certified by NCQA since 2007

NCQA Certified Utilization Management"Achieving Utilization Management Certification from NCQA demonstrates that ConnectCare has the systems, process and personnel in place to conduct utilization management in accordance with the strictest quality standards." -- Margaret E. O'Kane, President, NCQA

NCQA has reviewed and certified ConnectCare's Utilization Management functions only. For complete details on the scope of this review, visit www.ncqa.org.