Justification for Clinical Exception Request Process

Rationale: This document is to be completed by an individual’s therapist (OT/PT/SLP) when requesting more than 58 hours of ongoing therapy services per year to implement the corresponding Therapy Intervention Plan. (The Case Manager may approve a therapy exception of up to 72 hours for the first ISP year for a therapist new to that client).

Required Attachments:
For individuals not on the SARL:
The most recent Therapy Progress Report and Therapy Intervention Plan must be attached to the Justification for Clinical Exception Form and the Justification Narrative.  The MAD 046 and ARA worksheet must be obtained from the case manager and submitted with the therapist’s information.

For individuals on the SARL:
If the request is for additional therapy units required to implement the Therapy Intervention Plan for individuals who are on the SARL and the plan includes documentation of activities for the therapist to address aspiration risk management activities, you need to include only the Therapy Intervention Plan (that includes aspiration risk management activities), the MAD 046, and the ARA worksheet.

Criteria: 
There is no standard set of criteria.  Each case will be reviewed to assure that services are provided in compliance with the current Standards for Therapy (chapter 13 of the DD Waiver Standards). Reviewers recognize that individuals with DD are unique and require a unique plan for implementing therapy according to the Scope of Therapy defined in the DD Waiver Therapy Standards.

When due:   
Within the ISP year, as needed.  The Case Manager can submit the first 58 hours through the normal process.  We suggest that the Clinical Exception Request be submitted by the therapist at least eight weeks before additional hours are needed.

Due to: 
Clinical Services Bureau to the attention of OT or PT or SLP (address is on the form).  Should be sent via mail, not fax. 

AND The application form is due to the Case Manager to retain as documentation for individual’s case file.

Approval/ Denial: 
Provided to the requesting therapist AND the case manager within 30-calendar days via fax.

Denial Explanation Form:  
Will be sent to inform the therapist and CM of the reason for a denial. 

Budget (MAD046) Development: 
When a clinical exception is approved it will be faxed to the case manager.  The case manager is responsible to develop a budget as requested on the request form.  The case manager will have the provider sign the form and submit it for data entry.  There will not be a separate billing code for Clinical Exceptions.

For more information or for referrals, contact the Clinical Services Bureau - Therapy Services Team.

Read more about the Clinical Services Bureau (click here).