Statutes, codes, and regulations
Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.09-050 - Occupational, Physical and Speech Therapy Services Provider Manual Update #108, Physician/Independent Lab/Radiation Therapy Center #165, Rehabilitative Hospital #108, Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD) #152, Developmental Day Treatment Clinic Services (DDTCS) #119, Child Health Medical Services #116

016.06.09 Ark. Code R. 050

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Current through Register Vol. 49, No. 10, October, 2024
Rule 016.06.09-050 - Occupational, Physical and Speech Therapy Services Provider Manual Update #108, Physician/Independent Lab/Radiation Therapy Center #165, Rehabilitative Hospital #108, Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD) #152, Developmental Day Treatment Clinic Services (DDTCS) #119, Child Health Medical Services #116
214.310 Accepted Tests for Occupational Therapy

Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child should be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in the evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:

* STANDARD: Evaluations that are used to determine deficits.

* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.

* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.

A. Fine Motor Skills - Standard
1. Peabody Developmental Motor Scales (PDMS, PDMS2)
2. Toddler and Infant Motor Evaluation (TIME)
3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance (TIMP)
B. Fine Motor Skills - Supplemental
1. Early Learning Accomplishment Profile (ELAP)
2. Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)
4. Miller Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile (HELP)
7. Battelle Developmental Inventory (BDI)
8. Developmental Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory (BDI)
C. Visual Motor-Standard
1. Developmental Test of Visual Motor Integration (VMI)
2. Test of Visual Motor Integration (TVMI)
3. Test of Visual Motor Skills
4. Test of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual Test
2. Motor Free Visual Perceptual Test - R (MVPT)
3. Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper level) (TVPS)
E. Handwriting - Standard
1. Evaluation Test of Children's Handwriting (ETCH)
2. Test of Handwriting Skills (THS)
3. Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for Infants/Toddlers
2. Sensory Profile for Preschoolers
3. Sensory Profile for Adolescents/Adults
4. Sensory Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised (Sll-R)
6. Sensory Profile School Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance Analysis
2. Analysis of Sensory Behavior
3. Sensory Integration Inventory
4. DeGangi-Berk Test of Sensory Integration
H. Activities of Daily Living/Vocational/Other - Standard
1. Pediatric Evaluation of Disability Inventory (PEDI)

NOTE: The PEDI can also be used for older children whose functional abilities fall below that expected of a VA year old with no disabilities. In this case, the scaled score is the most appropriate score to consider.

2. Adaptive Behavior Scale - School (ABS)
3. Jacobs Pre-vocational Assessment
4. Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure - 7 years of age to adult (FIM)
9. Functional Independence Measure -young version (WeeFIM) I. Activities of Daily Living/Vocational/Other- Supplemental
1. School Function Assessment (SFA)
2. Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale

TOC not required

227.210Accepted Tests for Occupational Therapy

Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:

* STANDARD: Evaluations that are used to determine deficits.

* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.

* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.

A. Fine Motor Skills - Standard
1. Peabody Developmental Motor Scales (PDMS, PDMS2)
2. Toddler and Infant Motor Evaluation (TIME)
3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance (TIMP)
B. Fine Motor Skills - Supplemental
1. Early Learning Accomplishment Profile (ELAP)
2. Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)
4. Miller Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile (HELP)
7. Battelle Developmental Inventory (BDI)
8. Developmental Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory (BDI)
C. Visual Motor-Standard
1. Developmental Test of Visual Motor Integration (VMI)
2. Test of Visual Motor Integration (TVMI)
3. Test of Visual Motor Skills
4. Test of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual Test
2. Motor Free Visual Perceptual Test - R (MVPT)
3. Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper level) (TVPS)
E. Handwriting - Standard
1. Evaluation Test of Children's Handwriting (ETCH)
2. Test of Handwriting Skills (THS)
3. Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for Infants/Toddlers
2. Sensory Profile for Preschoolers
3. Sensory Profile for Adolescents/Adults
4. Sensory Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised (Sll-R)
6. Sensory Profile School Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance Analysis
2. Analysis of Sensory Behavior
3. Sensory Integration Inventory
4. DeGangi-Berk Test of Sensory Integration
H. Activities of Daily Living/Vocational/Other - Standard
1. Pediatric Evaluation of Disability Inventory (PEDI)

NOTE: The PEDI can also be used for older children whose functional abilities fall below that expected of a 71/2 year old with no disabilities. If this is the case, the scaled score is the most appropriate score to consider.

2. Adaptive Behavior Scale - School (ABS)
3. Jacobs Pre-vocational Assessment
4. Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure (FIM) 7 years of age to adult
9. Functional Independence Measure -young version (WeeFIM)
I.Activities of Daily Living/Vocational/Other- Supplemental
1. School Function Assessment (SFA)
2. Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale

TOC required

216.120 Accepted Tests for Occupational Therapy

Tests must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:

* Standard:Evaluations that are used to determine deficits.

* Supplemental:Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.

* Clinical observations:Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.

A. Fine Motor Skills - Standard
1. Peabody Developmental Motor Scales (PDMS, PDMS2)
2. Toddler and Infant Motor Evaluation (TIME)
3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance (TIMP)
B. Fine Motor Skills - Supplemental
1. Early Learning Accomplishment Profile (ELAP)
2. Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)
4. Miller Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile (HELP)
7. Battelle Developmental Inventory (BDI)
8. Developmental Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory (BDI)
C. Visual Motor-Standard
1. Developmental Test of Visual Motor Integration (VMI)
2. Test of Visual Motor Integration (TVMI)
3. Test of Visual Motor Skills
4. Test of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual Test
2. Motor Free Visual Perceptual Test - R (MVPT)
3. Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper level) (TVPS)
E. Handwriting - Standard
1. Evaluation Test of Children's Handwriting (ETCH)
2. Test of Handwriting Skills (THS)
3. Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for Infants/Toddlers
2. Sensory Profile for Preschoolers
3. Sensory Profile for Adolescents/Adults
4. Sensory Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised (Sll-R)
6. Sensory Profile School Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance Analysis
2. Analysis of Sensory Behavior
3. Sensory Integration Inventory
4. DeGangi-Berk Test of Sensory Integration
H. Activities of Daily Living/Vocational/Other- Standard
1. Pediatric Evaluation of Disability Inventory (PEDI)

NOTE:The PEDI can also be used for older children whose functional abilities fall below that expected of a IVi year old with no disabilities. In this case, the scaled score is the most appropriate score to consider.

2. Adaptive Behavior Scale - School (ABS)
3. Jacobs Pre-vocational Assessment
4. Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure - 7 years of age to adult (FIM)
9. Functional Independence Measure -young version (WeeFIM)
I. Activities of Daily Living/Vocational/Other - Supplemental
1. School Function Assessment (SFA)
2. Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale

TOC not required

218.120 Accepted Tests for Occupational Therapy

Tests must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:

* Standard:Evaluations that are used to determine deficits.

* Supplemental:Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.

* Clinical observations:Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.

A. Fine Motor Skills - Standard
1. Peabody Developmental Motor Scales (PDMS, PDMS2)
2. Toddler and Infant Motor Evaluation (TIME)
3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance (TIMP)
B. Fine Motor Skills - Supplemental
1. Early Learning Accomplishment Profile (ELAP)
2. Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)
4. Miller Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile (HELP)
7. Battelle Developmental Inventory (BDI)
8. Developmental Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory (BDI)
C. Visual Motor-Standard
1. Developmental Test of Visual Motor Integration (VMI)
2. Test of Visual Motor Integration (TVMI)
3. Test of Visual Motor Skills
4. Test of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual Test
2. Motor Free Visual Perceptual Test - R (MVPT)
3. Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper level) (TVPS)
E. Handwriting - Standard
1. Evaluation Test of Children's Handwriting (ETCH)
2. Test of Handwriting Skills (THS)
3. Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for Infants/Toddlers
2. Sensory Profile for Preschoolers
3. Sensory Profile for Adolescents/Adults
4. Sensory Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised (Sll-R)
6. Sensory Profile School Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance Analysis
2. Analysis of Sensory Behavior
3. Sensory Integration Inventory
4. DeGangi-Berk Test of Sensory Integration
H. Activities of Daily Living/Vocational/Other- Standard
1. Pediatric Evaluation of Disability Inventory (PEDI)

NOTE:The PEDI can also be used for older children whose functional abilities fall below that expected of a TA year old with no disabilities. In this case, the scaled score is the most appropriate score to consider.

2. Adaptive Behavior Scale - School (ABS)
3. Jacobs Pre-vocational Assessment
4. Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure - 7 years of age to adult (FIM)
9. Functional Independence Measure -young version (WeeFIM)
I. Activities of Daily Living/Vocational/Other - Supplemental
1. School Function Assessment (SFA)
2. Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale

TOC not required

220.110 Accepted Tests for Occupational Therapy

Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:

* STANDARD:Evaluations that are used to determine deficits.

* SUPPLEMENTAL:Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.

* CLINICAL OBSERVATIONS:Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.

A. Fine Motor Skills - Standard
1. Peabody Developmental Motor Scales (PDMS, PDMS2)
2. Toddler and Infant Motor Evaluation (TIME)
3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance (TIMP)
B. Fine Motor Skills - Supplemental
1. Early Learning Accomplishment Profile (ELAP)
2. Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)
4. Miller Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile (HELP)
7. Battelle Developmental Inventory (BDI)
8. Developmental Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory (BDI)
C. Visual Motor-Standard
1. Developmental Test of Visual Motor Integration (VMI)
2. Test of Visual Motor Integration (TVMI)
3. Test of Visual Motor Skills
4. Test of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual Test
2. Motor Free Visual Perceptual Test - R (MVPT)
3. Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper level) (TVPS)
E. Handwriting - Standard
1. Evaluation Test of Children's Handwriting (ETCH)
2. Test of Handwriting Skills (THS)
3. Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for Infants/Toddlers
2. Sensory Profile for Preschoolers
3. Sensory Profile for Adolescents/Adults
4. Sensory Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised (Sll-R)
6. Sensory Profile School Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance Analysis
2. Analysis of Sensory Behavior
3. Sensory Integration Inventory
4. DeGangi-Berk Test of Sensory Integration
H. Activities of Daily Living/Vocational/Other - Standard
1. Pediatric Evaluation of Disability Inventory (PEDI)

NOTE: The PEDI can also be used for older children whose functional abilities fall below that expected of a 71/2 year old with no disabilities. In this case, the scaled score is the most appropriate score to consider.

2. Adaptive Behavior Scale - School (ABS)
3. Jacobs Pre-vocational Assessment
4. Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure (FIM) 7 years of age to adult
9. Functional Independence Measure -young version (WeeFIM)
I. Activities of Daily Living/Vocational/Other- Supplemental
1. School Function Assessment (SFA)
2. Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale

TOC not required

220.200 Procedures for Extension of Benefits of CHMS

Diagnosis/Evaluation

A. Extension of benefits for medically necessary CHMS diagnosis and evaluation procedures may be requested. To request extension of benefits, submit a completed form DMS-699-A CHMS Benefit Extension for Diagnosis/Evaluation Procedures and additional medical records including the most recent multidisciplinary evaluation to substantiate medical necessity to AFMC. View or print CHMS Benefit Extension for Diagnosis/Evaluation Procedures form DMS-699-A and instructions for completion. View or print AFMC contact information.
B. AFMC, which includes medical personnel, will review the medical records and will notify the requesting provider of the approval or denial of the request. AFMC will forward the approved Benefit Extension Numbers to the provider for the procedure codes requested.
220.300Procedures for Extension of Benefits of CHMS

Diagnosis/Evaluation or Specified Treatment Services

To request benefit extensions for medically necessary CHMS diagnosis/evaluation procedure codes or specified treatment procedure codes:

Submit a CHMS Benefit Extension form and additional medical records including the most recent multidisciplinary evaluation to substantiate medical necessity to AFMC. View or print DMS-699-A CHMS Benefit Extension form and instructions for completion. View or print AFMC contact information.

AFMC, which includes medical personnel, will review the medical records and will notify the requesting provider of the approval or denial of the request. AFMC will forward the approved Benefit Extension Numbers to the provider for the procedure codes requested.

242.000Prior Authorization Request to Determine and Verify the Patient's

Need for Child Health Management Services

Intervention and treatment services for Medicaid beneficiaries must be prior authorized in accordance with the following procedures.

A. When a recommendation is made for intervention/treatment services, the CHMS Request for Prior Authorization form DMS-102 must be completed by the CHMS clinic and submitted via mail or fax to the Arkansas Foundation for Medical Care (AFMC). Fax transmission will be limited to 25 pages. For those clinics wishing to utilize electronic submission, contact AFMC and request specifics. View or print CHMS Request for Prior Authorization form DMS-102 and instructions for completion. View or print AFMC contact information.

The request must include a report of the findings from evaluations and a current plan for treatment. Review for medical necessity will be performed on the information sent by the provider. This information must substantiate the need for the child to receive services in a multidisciplinary CHMS clinic.

B. The request will be screened by the CHMS review coordinator.
1. When completed documents are received, a review for prior authorization of requested services will be performed. If the CHMS review coordinator cannot approve all of the procedure codes requested, the request form and documentation will be sent to a physician advisor for his or her determination.
2. There may be complete approval, partial approval or complete denial of procedure codes requested. Reconsideration may be requested within thirty (30) calendar days of the date on the denial letter.
3. Reconsideration review will be performed by a different physician advisor.
C. If services are approved, the requesting CHMS clinic will be issued an authorization number. A preliminary length of service, procedure codes and units approved will be designated.
D. In cases where the patient could be served at either a CHMS clinic or a Developmental Day Treatment Clinic (DDTCS), AFMC will notify the parents and the patient's primary care physician (PCP) of the options for type of clinic.
E. The determination by AFMC will be pended for a maximum of 30 days to allow the parent to choose the clinic where services will be provided.
F. Once the determination has been made, the CHMS clinic will be notified of the prior authorization disposition.
G. The prior authorization process will be completed within fifteen (15) working days of receipt of all required documentation. Intervention/Treatment Services may begin prior to the receipt of prior authorization only at the financial risk of the CHMS organization.

Refer to the flow chart in Section 244.000 of this manual for the process outlined above.

244.000Flow Chart of Intake and Prior Authorization Process for

Intervention/Treatment

View or print Flow Chart of Intake and Prior Authorization Process for Intervention/Treatment.

View or print DMS-102 CHMS Request for Prior Authorization Form and instructions for completion.

245.110Accepted Tests for Occupational Therapy

Tests used must be norm-referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for audit review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:

* STANDARD: Evaluations that are used to determine deficits.

* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.

* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.

A. Fine Motor Skills - Standard
1. Peabody Developmental Motor Scales (PDMS, PDMS2)
2. Toddler and Infant Motor Evaluation (TIME)
3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
4. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)
5. Test of Infant Motor Performance (TIMP)
B. Fine Motor Skills - Supplemental
1. Early Learning Accomplishment Profile (ELAP)
2. Learning Accomplishment Profile (LAP)
3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)
4. Miller Assessment for Preschoolers (MAP)
5. Functional Profile
6. Hawaii Early Learning Profile (HELP)
7. Battelle Developmental Inventory (BDI)
8. Developmental Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory (BDI)
C. Visual Motor-Standard
1. Developmental Test of Visual Motor Integration (VMI)
2. Test of Visual Motor Integration (TVMI)
3. Test of Visual Motor Skills
4. Test of Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual Test
2. Motor Free Visual Perceptual Test - R (MVPT)
3. Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper level) (TVPS)
E. Handwriting - Standard
1. Evaluation Test of Children's Handwriting (ETCH)
2. Test of Handwriting Skills (THS)
3. Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for Infants/Toddlers
2. Sensory Profile for Preschoolers
3. Sensory Profile for Adolescents/Adults
4. Sensory Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised (Sll-R)
6. Sensory Profile School Companion, First Edition-School Companion
G. Sensory Processing - Supplemental
1. Sensory Motor Performance Analysis
2. Analysis of Sensory Behavior
3. Sensory Integration Inventory
4. DeGangi-Berk Test of Sensory Integration
H. Activities of Daily Living/Vocational/Other - Standard
1. Pediatric Evaluation of Disability Inventory (PEDI)

NOTE: The PEDI can also be used for older children whose functional abilities fall below that expected of a 71/2 year old with no disabilities. In this case, the scaled score is the most appropriate score to consider.

2. Adaptive Behavior Scale - School (ABS)
3. Jacobs Pre-vocational Assessment
4. Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living Skills
6. Cognitive Performance Test
7. Purdue Pegboard
8. Functional Independence Measure (FIM) 7 years of age to adult
9. Functional Independence Measure -young version (WeeFIM)
I. Activities of Daily Living/Vocational/Other- Supplemental
1. School Function Assessment (SFA)
2. Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person Scale

016.06.09 Ark. Code R. 050

1/12/2010