Next Generation Solutions Detailed Request Checklists For .

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Next Generation SolutionsDetailed Request Checklistsfor Speech-LanguageTherapy ServicesUpdated 1 2/01/20208600 West Bryn Mawr AvenueSouth Tower – Suite 800 Chicago, IL fordable 2020 AIM Specialty Health2093-0419

Getting ready to place a requestKnowing what information you will need for each request saves time. Our Speech-Language services requestchecklist can help you identify and collect the information you need to have available when entering a request.We recommend that you print a copy or save it to your computer to keep it handy when you are preparing tosubmit a request.Place of Services: Speech-Language services performed in the following settings require pre-authorization fromAIM Specialty Health: OfficeOutpatient Hospital (On-campus or Off-campus)Independent ClinicOther settings (e.g., Inpatient Hospital, Inpatient rehabilitation facilities, school, etc.) are not managed by AIMSpecialty Health. Please refer back to the health plan.INFORMATION YOU WILL NEED FOR SPEECH-LANGUAGE PATHOLOGY THERAPY SERVICES REQUESTSFor all requests, you will need: Member first and last name, date of birth, member ID Ordering (referring) provider TIN/NPI, first and last name. If you have difficulty finding the provider, pleasecall the AIM call center to initiate the pre-authorization request. Servicing facility, TIN/NPI (including types such as outpatient hospital or office) Treating therapist, TIN/NPI, first and last name (if known) CPT code(s) you are requestingo Refer to the Rehabilitation Program CPT code list for the codes that require prior authorization andmay require individual adjunctive CPT codes to be entered separately on every request. ICD-10 diagnosis code associated with request (one ICD-10 per request, recommend using the primarytreating diagnosis unless required by your state to use referring physician’s diagnosis) Date of evaluation and related treatment sessions to this episode of careo Ensure to input the same evaluation date on every request related to the member’s episode ofcare Functional Outcome Tool(s) (patient-reported or therapist-reported, diagnostic assessments (see list ofincluded, common tools in Appendix A)o Example: OWLS- Oral and Written Language Scaleso No score required Primary purpose of therapy (e.g. rehabilitation, habilitation, maintenance, massage, taping) Please refer toAIM Outpatient Rehabilitation & Habilitation Clinical Guidelines for specific definitions. Category of treatment (e.g. speech-language, swallowing, and/or cognitive-communication-hearing) To confirm that a complete plan of care is documented, there is an expectation of achievable improvementin a reasonable timeframe, and that services are being delivered by a licensed provider of speechlanguage therapy2

Referencing the following documentation and information during requests may be necessary and possiblyrequested for upload at the time of review:-Evaluation and Plan of CareoooooooObjective assessment including functional tool(s) and score(s) if applicable. (scores notrequired for most speech language tools)Medical history including associated conditions, comorbidities, and/or clinical informationthat may impact treatment (e.g. cognitive impairment, head and neck cancer, respiratorydisorder, substance abuse, hearing or vision impairments) See APPENDIX B below for a morecomplete list.Surgical history or injuryOther treatments or previous therapyLevel of impairment and/or level of cueing (required except in some pediatric cases when notapplicable)Functional or activity limitationsNumber of short and/or long term goals established by the evaluating provider-Treatment daily documentation notes-Progress notesoooooObjective assessmentUpdated level of impairment and/or level of cueing (required except in some pediatric caseswhen not applicable)Number of short and/or long term goals met and not met; including progression towardsfunctional goalsFactors impeding progressAny revisions to the original plan of careAdditionally, for Pediatric Habilitative service, you will need to know:ooIf there is a confirmed diagnosis of an Autism Spectrum Disorder and/or Pervasivedevelopmental delay as well as the severity level (using standardized criteria, e.g. DSM V)Medical history including associated conditions, comorbidities, and/or clinical informationthat may impact treatment (e.g. intellectual disability, seizures, sensory processing disorder,spasticity or contractures, social determinants of health). See APPENDIX B below for a morecomplete list.3

Appendix A – Functional ToolsFunctional Tool Name & AbbreviationScoring Scale (if grey – no scorewill be required for input)ADOS-2 - Autism Diagnostic Observation Schedule, Second EditionArizona-4 - Arizona Articulation and Phonology ScaleBADS -Behavioral Assessment of the Dysexecutive SyndromeBatelle Developmental Inventory ScoringBBTOP- Bankson-Bernthal Test of PhonologyBDAE3- Boston Diagnostic Aphasia Examination-3BNT - Boston Naming TestCAAP- Comprehensive Assessment of Articulation/ PhonologyCADL- Communicative Abilities of Daily LivingCASL - Comprehensive Assessment of Spoken LanguageCCC-2 Children's Communication Checklist-2CELF- Clinical Evaluation of Language Fundamentals 4th Edition , 5th edition,PediatricsCFCS- Communication Function Classification SystemCLQT - Cognitive Linguistic Quick TestCognistatDAYC- 2- Developmental Assessment of Young Children-2DP-3 - Developmental Profile-3EASIC-3- Evaluation of Acquired Skills in Communication, 3rd EditionEDACS- Eating and Drinking Ability Classification SystemEOWPT- Expressive One-Word Picture Vocabulary TestEVT- Expressive Vocabulary TestFCM/ NOMS - Functional Communication Measures / National OutcomesMeasurement SystemFIM - Functional Independence measureG- Code Functional Reporting: G8996 Swallow, G8999 Motor Speech, G9159 SpokenLanguage Comprehension, G9165 Attention, G9168 Memory, G9171 Voice, G9174Other speech-language pathologyGFTA - Goldman Fristoe Test of ArticulationGoldman Fristoe Test of Articulation 3rd edition18 - 1260 - 100 percentage orcorres ponding modifierKLPA-3- Khan-Lewis Phonological Analysis, 3rd editionLPT- Language Processing TestMacArthur-Bates Communication Development InventoriesMCHAT- Modified Checklist for Autism in Toddlers, RevisedMMSE - Mini mental state examination0 - 30MOCA - Montreal Cognitive AssessmentOWLS- Oral and Written Language ScalesPediatric Test of Brain InjuryPLS-5 - Preschool Language ScalePPVT - Peabody Picture Vocabulary TestRBANS- The Repeatable Battery for the Assessment of Neuropsychological StatusUpdateRBMT3 -Rivermead Behavioral Memory Test Third EditionREEL - Receptive Expressive Emergent Language TestRIPA-P - Ross Information Processing Assessment4

Functional Tool Name & AbbreviationRossetti Infant Toddler Language ScaleROWPVT- Receptive One-Word Picture Vocabulary TestSLDT- Social Language Development Test-Elementary/ AdolescentSlosson Oral Reading ProfileSLUMS - Saint Louis University Mental StatusSPAT-D- Structured Photographic Articulation TestSRS-2- Social Responsiveness Scale, Second EditionSSI- Stuttering Severity InstrumentSSIS- Social Skills Improvement System Rating ScalesTAPS- Test of Auditory ProcessingTASP- Test of Aided-Communication Symbol PerformanceTECEL- Test of Early Communication and Emerging LanguageTILLS- Test of Integrated Language and Literacy SkillsTNL-2- Test of Narrative Language- 2nd editionTOAL-4- Test of Adolescent and Adult Language-4TOLD-P/I- Test of Language Development Primary or IntermediateTOPL- Test of Pragmatic LanguageTOPS - Test of Problem SolvingVineland Adaptive Behavior ScaleWABC- Wiig Assessment of Basic Concepts5Scoring Scale (if grey – no scorewill be required for input)

Appendix B - Comorbidities / Associated health conditionsDepending on the clinical scenario of the individual patient, the following comorbidities may be listed. Pleasebe prepared with any that impact your patient therapy services.Adults and Pediatrics:oooooooooooooooSocial determinants of health (E.g. nutrition, housing, education, transportation)Respiratory disorder (E.g. asthma, COPD, pulmonary fibrosis, oxygen use)Cognitive or intellectual impairment (E.g. brain injury, learning disability, concussion, aphasia)Active major medical treatment (E.g. radiation, chemotherapy, hemodialysis)Neurological condition (E.g. prior stroke, Parkinson’s, MS, seizures)Current medical devices (E.g. PEG tube, catheter, shunt, tracheostomy)Psychological disorder (E.g. bipolar, ADHD, schizophrenia)Non-developmental impairment (E.g. uncorrected hearing or vision loss)Sensory processing disorder (E.g. apraxia, hemi-neglect)Gastrointestinal disorder (E.g. GERD, diverticulum)Structural or anatomic abnormality (E.g. cleft palate, stricture)Substance abuse (E.g. alcohol, illicit drugs, heavy smoking)DysphagiaFlaccid DysarthriaHead or neck cancer6