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Therapy Evaluation and Plan of Care

Physical therapist working with young girl on inclined cushion.

The Division has specific requirements for Therapy Evaluations and Plans of Care as outlined in the Provider Manual Chapter 37- Therapy Services- Occupational, Physical and Speech Language which support positive member outcomes and overall best practices. In support of these requirements, the Division has provided the documents, training and FAQs below:

Provider Training PowerPoint PDF

Flowchart for Establishing and Re-certifying Therapy Services

Evaluation Report and Plan of Care (Evaluation-POC)

Ongoing Quarterly Progress Report and Plan of Care (QPR-POC)

FAQ - Therapy Evaluation 

Q: Who is responsible for obtaining a medical prescription/referral for a therapy evaluation?
A: The responsible person is responsible for obtaining the medical prescription from the member’s primary care provider (PCP) for an evaluation.

Q: When can therapy services start to be provided after the initial evaluation is completed?
A: The Qualified Vendor must provide the member's Support Coordinator with a copy of the Certified Plan of Care before the services can be authorized in Focus. The Support Coordinator must receive the Certified Plan of Care within three weeks of the completed evaluation.

Q: What does the evaluation valid order have to say?
A: The order must contain the following:

  • Must be completed by the member’s ordering prescriber: 
    • Primary Care Provider (PCP) or attending Physician, or 
    • Medical Doctor (MD), or
    • Doctor of Osteopathy (DO), or
    • Physician Assistant (PA), or
    • Nurse Practitioner (NP)
  • Must identify the Therapy Discipline: 
    • Occupational Therapy 
    • Physical Therapy
    • Speech-Language Pathology
    • Feeding evaluation requests must be specific to a Therapy Discipline (i.e. OT/Feeding evaluation, SLP/Feeding evaluation)
    • Feeding/Swallowing therapy must be on a separate/distinct order from OT or Speech orders/CPOCs
  • Must include a therapy service description or Current Procedural Terminology (CPT) Code for the treatment services that most appropriately represent the proposed procedures or services established.
  • Must include the therapy amount: Number of Evaluation Units
  • Must include the first and last name of the ordering provider or provider’s NPI number 
  • Must include the signature of the ordering provider (electronic or wet signature)
  • Must include the date of order

Q: Who do I contact if, as a qualified vendor we have difficulty getting an evaluation authorization?
A: The Support Coordinator or their Supervisor.

Q: Can evaluations be approved annually if needed or will evaluations ONLY be approved every three years?  
A: Evaluations may be approved as needed. Please refer to the Evaluation Triggers listed on pages 3 and 4 of the Flowchart for Establishing and Re-certifying Therapy Services.

Q: How soon can treatment be started after an initial evaluation is completed?
A: The Qualified Vendor must provide the member's Support Coordinator with a copy of the Certified Plan of Care prior to the Support Coordinator authorizing services. The Support Coordinator must receive the Certified Plan of Care within 21 days of the completed evaluation.  Treatment should not begin until the Qualified Vendor receives the authorization in Focus.

Q: If a new evaluation is completed for a member currently receiving services, is this the new date that the 90-days starts from?
A: The first Quarterly Progress Report is due 90-days from the date of the evaluation and each subsequent Quarterly Progress Report will continue on the 90-day cycle.

FAQ - Plan of Care

Q: Can Qualified Vendors providing therapy services continue to use their own forms/systems or do they have to use the new QPR-POC form?
A: Qualified Vendors (QV) providing therapy services are not required to use the new Quarterly Progress Report (QPR)/Plan of Care (POC) form.  The DDD QPR-POC is available to QVs who may not have their own clinical form or access to an electronic medical record (EMR) system. For those QVs who opt to use their own forms or EMR, the DDD QPR-POC can be used as a reference since it contains the minimally required information, i.e., the member’s treatment diagnosis, long-term treatment goals as well as the type, amount, duration, and frequency of therapy services. 

Q: What is a Plan of Care (POC)?
A: A POC is a written treatment plan developed by the evaluating therapist based on the objective findings of the evaluation. If the results from an evaluation substantiate a recommendation for medically necessary therapy services, the therapist should develop a POC and send it to the PCP for certification. 

Q: What is the difference between the POC and the Certified POC?
A: The POC is the plan developed by the evaluating therapist and the Certified Plan of Care is a copy of the POC signed and dated by the member’s PCP. The Certified POC becomes the prescription for therapy treatment services.

Q: What information should the POC include?
A: The POC must contain at a minimum the member’s treatment diagnosis, long-term treatment goals as well as the type, the expected length of visits (e.g., one-hour sessions), frequency (e.g., two times a week), and duration (e.g., three months) for the proposed therapy service. It should also include the discharge criteria. The signature and professional identity of the person who established the plan of care and the date it was established must also be documented within the POC. 

Q: Once the POC is created, what do I do next?
A: Creating the POC is different from certifying the POC. The Centers for Medicare and Medicaid states that certification of the POC requires a dated signature on the POC by the physician or non-physician practitioner who is the primary care provider (PCP) for the member as well as the PCP’s NPI number. The certification of the POC should occur as soon as possible as the qualified vendor must provide the member’s Support Coordinator (SC) with a copy of the certified POC prior to authorization of services. The SC must receive the certified POC within three (3) weeks of the completion of the evaluation. The certified POC will serve as the medical prescription referral for therapy treatment services. Please be aware that a face-to-face visit with the member may be required by the PCP.

Q: Why do we as providers/qualified vendors need to get the PCP to sign the POC?
A: Meeting our member’s needs is a team effort. The team includes the member, the responsible person (when applicable), DDD, and all of the member’s healthcare providers. The referring PCP is an integral member of this team and the POC is a means of communicating the member’s functional status, therapy goals, and their progression towards the achievement of the established goals. Communication with the member’s PCP, via the POC, allows for a more coordinated and integrated form of care enhancing services and improving the quality of care. The evaluating therapist is most qualified to answer any questions the PCP may have regarding the recommended therapy services outlined in the POC.

Q: Does the POC need to be signed by the PCP every quarter? 
A: No, the certified POC serves as the medical prescription for therapy treatment services, therefore a new Certified POC will only be required prior to the end of the previous authorization period. If the objective therapy data and clinical judgment support continued therapy treatment, the qualified vendor should update and recertify the POC, as needed, at least annually with a dated PCP signature and NPI number.

Q: Since the Certified POC is considered the prescription, the only time a therapist should actually need to get a doctor prescription/referral would be for an evaluation, correct?
A: Yes, the certified POC is the prescription/referral for continued therapy treatment services. The treating therapist needs to update the POC at the end of the authorization/certification period if the recommendation is that services need to be continued.

Q: Can I use a cover sheet instead of a POC for a PCP to sign? 
A: No. The POC must contain at a minimum the member’s treatment diagnosis, long-term treatment goals as well as the type, amount, duration, and frequency of therapy services.

Q: Does the POC go to the SC through email or the FTP site? 
A:  It can be submitted via the FTP site with the evaluation or the quarterly progress report.

Q:  Do we have to use the DDD quarterly progress report and POC?  
A: Providers may use their discretion to determine the format of the POC. Qualified vendors may use their own EMR or the DDD template. However, a provider must ensure the forms they are using include, at minimum, the same information that is on the Division's template.

FAQ - Updating the POC

Q: When will an updated POC be due?
A: If objective therapy data and clinical judgment confirm the need for continued therapy treatment, the Qualified Vendor needs to provide the member's PCP with an updated POC prior to the end of the authorization/certification period.  In order to avoid access to care issues, DDD’s policy states the Qualified vendor shall complete the updates and obtain the PCP’s signature on the new POC 30 days in advance of the authorization/certification period end date.

Q: Can the 4th quarterly report be used as the POC?
A: Yes, an updated POC is completed by the therapist and submitted to the PCP for authorization/certification, and provided to DDD 30 days prior to the end of the certification period. 

FAQ - Authorizations

Q: What date on the POC aligns with the authorization?
A: The authorization will be started on the date the valid CPOC is received by the Division.

Q: After the end of the member’s previous authorization period, do I have to update the Plan of Care?
A: Yes, an updated POC is required to be submitted to the member’s PCP for certification. Therapy service authorizations will not be issued without a Certified POC. Therapy services are ONLY authorized when a Support Coordinator receives a Certified POC..

Q: After the Ordering Medical Professional signs the plan of care, how long do I have to provide the new CPOC to DDD?
A: The new CPOC should be provided as soon as possible to avoid any gaps in service.   If there are delays in providing the CPOC to the Division, the authorization will need to be adjusted and only the remaining units will be entered into Focus.   For example, if the PCP signed the CPOC on 9/1/2022 for 1 unit a week for 52 weeks, but it was not provided to the Division until 6/1/2023, 39 weeks later, the authorization would only be entered for 13 units, covering the 13 weeks left in the plan of care’s certification period

Q: Can a Therapy Qualified Vendor request that the member’s PCP backdate a CPOC in order to avoid a gap in service?
A: The DDD member’s PCP cannot attest to agreeing with the established POC prior to the date they review it. In order to assist in avoiding access to care issues, DDD’s policy states the Qualified vendor shall complete the updates and obtain the PCP’s signature on the new POC 30 days in advance of the authorization/certification period end date. 

FAQ - Other

Q: What is ROPA and how does that affect getting a CPOC signed?
A: The Patient Protection and Affordable Care Act (ACA) and the 21st Century Cures Act (Cures) require that all healthcare providers who refer AHCCCS members for an item or service, who order non-physician services for members, who prescribe medications to members, and who attend/certify medical necessity for services and/or who take primary responsibility for members’ medical care must be registered as AHCCCS providers. AHCCCS calls this initiative, and these providers, "ROPA.”   Therapy services must be signed off by an AHCCCS registered primary care provider or attending physician, including a medical doctor, doctor of osteopathy, physician assistant, or nurse practitioner in order for the claims to be paid.  For additional information on ROPA and to determine if the health care provider signing your CPOC is an AHCCCS registered provider, please visit Referring, Ordering, Prescribing, Attending (ROPA) Providers Required to Register with AHCCCS.

Q: How do I contact the Customer Service Center if I have questions?
A: The Customer Service Center can be reached by phone at 1 (844) 770-9500 ext. 1 or by email at [email protected].

Q: How do we bill when providing services via Telehealth?
A: As of July 1, 2023, teletherapy rates for therapy services are published in the Division’s Rate Book.

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