Prior Authorization Request (Occupational Therapy Services)

Request Type: [Initial / Continuation / Expedited]

Payer/Plan: [Payer name and product line]

Member Name: [Full name as on insurance card]

Date of Birth: [MM/DD/YYYY]

Member ID: [Member ID]

Evaluation Date: [MM/DD/YYYY]

Requested Authorization Period: [From MM/DD/YYYY to MM/DD/YYYY]

Referring Provider: [Name, credentials, NPI]

Rendering OT Provider: [Name, credentials, license number with state]

Facility: [Name, full address, NPI, phone, fax]

Executive Summary

(Provide a decision snapshot readable in under 30 seconds. Ensure this section matches the Plan of Care and Authorization Request Summary exactly.)

• Primary Diagnosis: [Diagnosis name, ICD-10 code, onset or surgery date]
• Functional Problem Statement: [One line linking impairment to ADL/IADL/work/education participation limitation]
• Key Baseline Objective Findings: [2–4 measures with values: standardized scores, ROM, strength, assist levels, task completion time]
• Request: [Setting], [X visits/week], [Y weeks], [Z total visits]
• Long-Term Goals: [2–3 measurable functional goals with timeframe]
• Why Skilled OT Now: [Brief reason skilled intervention is required; expected consequence without intervention]

Clinical Background

(Include only information relevant to OT dosing, safety, or prognosis. Omit unrelated medical history.)

• Mechanism/Context: [Injury/condition context; procedures with dates if applicable]
• Precautions/Restrictions: [Weight-bearing, ROM limits, lifting, splint schedule, other]
• Relevant Comorbidities: [Only those impacting participation, safety, or progression]
• Prior Treatment History: [Prior therapy episodes with dates/visits, hospitalizations, injections, relevant imaging] (For unavailable items: "Not available—requested on [date]" or "Will provide upon request.")

Evaluation Summary & Functional Status

(Document objective baseline. Clearly label patient-reported content. Do not infer or fabricate scores.)

• Primary Occupations Affected: [Brief list] (Patient report)
• Patient Stated Goals: [1–2 concise quotes or paraphrased goals] (Patient report)
• ADL/IADL Assistance Levels: [Independent / Setup / Supervision / Min A / Mod A / Max A / Dependent] for [key tasks; note device/orthosis if used]
• Safety Concerns: [Falls risk, impulsivity, impaired insight, skin integrity, driving, home safety] (Include only if present)
• Standardized Outcome Measures: [Tool name, score, interpretation] (If unable to complete, state reason and alternative measure used.)
• Impairment Measures: [ROM, strength, pain, edema, sensation, coordination, cognition as applicable with specific values]
• Clinical Impression: [Synthesis linking impairments to activity limitations and participation restrictions]
• Prognosis: [Good / Fair / Poor] for [expected timeframe]

Functional Deficits

(Present as a problem list. Include one entry per functional problem.)

• [Problem title framed around occupation, e.g., "Dressing limited by R wrist stiffness and pain"]
  • Baseline: [Measurable status: assist level, time, score, or quantity]
  • Contributing Impairments: [Key deficits driving the problem]
  • Impact if Untreated: [Safety risk, loss of independence, caregiver burden, delayed recovery]
  • Why Skilled OT Required: [Justification versus unskilled care or independent HEP]
• (Add additional problems as needed)

Medical Necessity Rationale

(Explain why skilled OT services are medically necessary. Avoid vague phrases like "tolerated well" without measurable support.)

• Skilled Judgment Required: [Graded progression, safety monitoring, orthotic management, adaptive strategy selection, complex education]
• Why Goals Cannot Be Achieved Without Skilled OT: [Limitations of independent HEP, caregiver assistance alone, or non-skilled supervision; complexity; risk profile]
• Frequency/Duration Justification: [Tie to tissue healing timelines, baseline severity, medical restrictions, need for monitoring/progression]
• If Maintenance Purpose: [Explicitly state maintenance to prevent decline, why skilled oversight is required, and objective indicators of risk for deterioration] (Include only if applicable)

Goals

(Long-term goals represent episode-level functional outcomes achievable within the requested authorization window. Include conditions such as "with orthosis" or "within precautions" when applicable. Add short-term goals only if payer requires.)

Problem Area	Baseline	Target	Measure	Timeframe
[Occupation/task targeted]	[Current measurable status]	[Desired functional status with assist level/quality/time/score]	[Tool or method]	[Target date or visit count]
[Additional goals as needed]

Plan of Care

• Type: Occupational Therapy
• Frequency: [X visits/week]
• Duration: [Y weeks]
• Total Visits Requested: [Z]
• Setting: [Outpatient clinic / Home / Inpatient rehab / SNF / Other]
• Planned Interventions: [ADL/IADL training; Therapeutic exercise/activity; Neuromuscular re-education; Manual therapy/edema/scar management; Orthotic fabrication and training; Sensory re-education; Cognitive/perceptual training; Home safety assessment; Patient/caregiver education with HEP progression] (Include only applicable interventions)
• Anticipated CPT Codes: [Code list with typical units per visit] (Include if payer requires; note actual mix may vary based on daily presentation)
• Discharge Criteria: [Functional thresholds for discharge, transition to self-management/HEP, equipment recommendations]

Progress Summary

(Include this section only for Continuation/Reauthorization requests. Omit entirely for Initial requests.)

• Prior Authorization Period: [From–To dates], [Visits authorized], [Visits used]
• Attendance/Compliance: [Attendance rate; note missed visits if clinically relevant]
• Objective Progress: [Baseline vs current values for each key measure and goal]
• Goal Status: [Met / Progressing / Not met with reason]
• Clinical Course: [If plateau or regression, explain factors and justify why continued skilled OT is expected to be effective or why maintenance is indicated]
• Plan Modifications: [Updates to frequency, interventions, HEP, orthoses, or precautions]

Authorization Request Summary

(Must match Executive Summary and Plan of Care exactly.)

Service	CPT/HCPCS Codes	Units per Visit	Visits per Week	Total Visits	Date Span	Place of Service
Occupational Therapy	[Codes or "Per payer policy"]	[Typical units]	[X]	[Z]	[MM/DD/YYYY to MM/DD/YYYY]	[Setting]

Attachments

• [ ] Full OT evaluation (signed/dated)
• [ ] Plan of care
• [ ] Referring provider order/referral
• [ ] Relevant operative or specialist notes
• [ ] Prior therapy discharge summary (for continuation requests)
• [ ] Outcome measure forms

(For missing items, note: "Not available—requested on [date]" or "Will provide upon request.")

Attestation & Signature

I attest that the information provided is accurate to the best of my knowledge and that the requested occupational therapy services are medically necessary and require the skills of a qualified occupational therapist.

Rendering OT Signature: ________________________________ Date: ____/____/________

Name/Credentials/License #: [Name, credentials, license number]

(If payer requires referring provider signature:)

Referring Provider Signature: ________________________________ Date: ____/____/________

Transmission Status: [Signed and on file / Signature requested on date / Will provide upon request]

(Meta-instructions: For required administrative fields—member ID, diagnosis, visits requested, provider credentials—use "REQUIRED—DO NOT SUBMIT BLANK" if information is missing. Do not infer or fabricate objective test results, assistance levels, or therapy units. Clearly label patient-reported information. For clinically important but sometimes unavailable elements such as imaging or prior records, document availability status rather than leaving blank.)