Skip to Main Content

Update: PT/OT/ST Therapy Evaluations - Prior Authorization Clarification

Date: 06/07/19

Heritage Health (Medicaid):

Nebraska Total Care, in working with therapy providers and stakeholders, is in the process of updating prior authorization requirements for PT/OT/ST evaluation and re-evaluation services. Nebraska Total Care will not require prior authorization for two evaluations done in the fiscal year, July 1st-June 30th, to support evaluation needs for diagnostic changes or provider change.  Additionally, Nebraska Total Care will not require prior authorization for the re-evaluation codes.

Nebraska Total Care anticipates completing our systemic update to reflect these changes by July 1st, 2019.  These updates will be retro-actively effective for dates of service April 1st, 2019 forward.  Once the system update is complete Nebraska Total Care will reprocess impacted claims for dates of service April 1st, 2019 forward.

The set of PT/OT evaluation codes this applies to is:

  • 97161   97165   97169   97750
  • 97162   97166   97170   97755
  • 97163   97167   97171


Prior Authorization is not required for PT and OT re-evaluation codes:

  • 97164
  • 97168
  • 97172


The set of ST evaluation codes this applies to is:

  • 92610   92523   92597   92607
  • 92521   92524   92605  
  • 92522   92551   92608


If you have questions, please contact Provider Relations.

7/26/19 Update: Nebraska Total Care has completed the systemic updates related to authorizations for PT/OT/ST evaluations and re-evaluations and a reprocessing project for the impacted claims from April 1, 2019, forward has been submitted under the following project number: PROJ-77645498.  This project has been added to our Known Issues Log under “Special Projects in Process”.