Skip to Main Content

PT/OT/ST OTR Form Update

Date: 08/30/19

Heritage Health (Medicaid):

On October 1, 2019, Nebraska Total Care will post a revised version of the Outpatient Treatment Request Form (OTR) for Therapy Authorizations. The updated form will support improved efficiencies for the routing and processing of authorization requests. An additional provider news notice will be posted with a link to the form ahead of October 1, 2019.

 

9/24/2019 Update: Outpatient Medicaid Authorization PT/OT/ST Form (PDF) (effective 10/01/2019)

01/06/2021 Update: Outpatient Medicaid Authorization PT/OT/ST Form (PDF)  (effective 12/30/2020)

11/28/2023 Update: Outpatient Medicaid Authorization PT/OT/ST Form (PDF)  (effective 09/06/2023)

12/10/2024 Update: Outpatient Medicaid Authorization PT/OT/ST Form (PDF)  (effective 12/10/2024)

01/01/2025 Update: Outpatient Medicaid Authorization PT/OT/ST Form (PDF)  (effective 01/01/2025)