1. (a) Coverage. Payment is made to registered physical therapists as set forth in this Section.

   1. (1) Children. Initial therapy evaluations do not require prior authorization and must be provided by a fully licensed physical therapist. All therapy services following the initial evaluation must be prior authorized for continuation of service. Prior to the initial evaluation, the therapist must have on file a signed and dated prescription or referral for the therapy services from the member's physician or other licensed practitioner of the healing arts. The prescribing or referring provider must be able to provide, if requested, clinical documentation from the member's medical record that supports the medical necessity for the evaluation and referral.
   2. (2) Adults. There is no coverage for adults for services rendered by individually contracted providers. Coverage for adults is permitted in an outpatient hospital setting as described in Oklahoma Administrative Code (OAC) 317:30-5-42.1.
   3. (3) Individuals eligible for Part B of Medicare. Services provided to Medicare eligible recipients are filed directly with the fiscal agent.
2. (b) Payment rates. All physical therapy services are reimbursed per the methodology described in the Oklahoma Medicaid State Plan.
3. (c) Procedure codes. The appropriate procedure codes used for billing physical therapy services are found in the Physicians' Current Procedural Terminology (CPT) Coding Manual.

317:30-5-291v2. Coverage by category¹

Payment is made to registered physical therapists as set forth in this Section.

1. (1) Children. Initial therapy evaluations do not require prior authorization and must be provided by a fully licensed physical therapist. All therapy services following the initial evaluation must be prior authorized for continuation of service. Prior to the initial evaluation, the therapist must have on file a signed and dated prescription or referral for the therapy services from the member's physician or other licensed practitioner of the healing arts. The prescribing or referring provider must be able to provide, if requested, clinical documentation from the member's medical record that supports the medical necessity for the evaluation and referral.
2. (2) Adults. There is no coverage for adults for services rendered by individually contracted providers. Coverage for adults is permitted in an outpatient hospital setting as described in Oklahoma Administrative Code (OAC) 317:30-5-42.1.
3. (3) Individuals eligible for Part B of Medicare. Services provided to Medicare eligible recipients are filed directly with the fiscal agent.
4. (4) Alternative treatments for pain management. Refer to OAC 317:30-5-728.

Editor's Note: ¹In 2022, the agency promulgated two permanent amended versions of this Section (317:30-5-291) with the same effective date (9-12-22). Therefore, both versions are published herein until the agency reconciles the two versions. 

Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency)

Added at 12 Ok Reg 3131, eff 7-27-95

Amended at 19 Ok Reg 2922, eff 7-1-02 (emergency)

Amended at 20 Ok Reg 1193, eff 5-27-03

Amended at 25 Ok Reg 123, eff 8-1-07 (emergency)

Amended at 25 Ok Reg 1192, eff 5-25-08

Amended at 29 Ok Reg 477, eff 5-11-12

Amended at 30 Ok Reg 336, eff 1-14-13 (emergency)

Amended at 30 Ok Reg 1163, eff 7-1-13

Amended at 38 Ok Reg 411, eff 2-1-21 (emergency)

Amended at 38 Ok Reg 1006, eff 9-1-21

Amended at 39 Ok Reg 419, eff 1-1-22 (emergency)

Amended at 39 Ok Reg 1425, eff 9-12-22