Medi-Cal and other health insurers require that “medical ...



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Medi-Cal and other health insurers require that “medical necessity” for speech and language services be established prior to reimbursement. For school-provided services, the District Physician has established the following criteria for medical necessity. Some health insurers may establish their own criteria for medical necessity that differ from the District’s.

1. The etiology of a speech or language impairment (i.e. developmental or acquired) does not in itself determine whether a service is medically necessary. This is based on the nature and severity of the disability.

2. A service qualifies as medically necessary if it supports a need that meets the criteria set forth in: 4/00 Eligibility Summary - Speech or Language Impairment (SLI). With C.C.R. Title 5 - Article 2.5 Section 3030, and 56333 including C.F.R. Part 300 Sec. 300.7, 300.530-300.536 for the California Education Code.

3. Services that do not qualify as medically necessary using the above-referenced document, may still be considered medical necessary if reviewed and labeled as such by a licensed physician.

4. Speech and Language assessments that qualify a student for services must be documented in writing.

5. Reasonable effort must be made to ensure that students’ physicians (or designated “medical home”) receive the results of each speech/language assessment, including recommended therapy.

6. The interval prior to reassessment should not exceed the period required by the Special Education Department for the Individualized Education Plan (IEP). This is currently 3 years.

7. The physician designated by the District is to be available to audit records of those services which the District is billing for, and where medical necessity is a requirement for reimbursement.

8. These criteria are to be reviewed at least every two years.

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Physician's Name (Printed or Typed) National Provider ID (NPI) #

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Physician's Signature California License #

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Date Fiscal Years Covered

Provider is an active Ordering, Referring, Prescribing (ORP) Medi-Cal Provider

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