Direct Billing : Therapy

child playing blocksSchools are legally required to provide Individuals with Disabilities Education Act (IDEA) related health services at no cost to eligible students. Medicaid reimbursement is available for these services per section 1903(c) of the Act, which requires Medicaid to be primary to the U.S. Department of Education for payment of the health-related services provided under IDEA. Medicaid will pay for Individual Education Plan (IEP) specified medical services and related administrative costs provided to Medicaid children. The 1903(c) exception is very specific and does not extend to services provided pursuant to a section 504 plan. 

IEP Guidelines for Therapy 

Before therapy services may be billed for a student, an IEP referencing the related therapy service must be in place. Once a referral is made for related services, the IEP team should determine the need for evaluation and services. 

Therapy Evaluation 

The Division of Elementary and Secondary Education (DESE) and educational institutions within the authority of the DESE (i.e. public school districts, educational service cooperatives, public school district-associated pre-k programs) is permitted to perform evaluations for children ages three (3) to twenty-one (21) years of age for educational/school-related purposes. Evaluations conducted on behalf of an educational institution and within Individual Education Plan (IEP) guidelines and requirements is valid for a three (3)-year period from the date the evaluation is conducted.
 
The evaluation may transfer with a student between educational institutions. The educational institution must draft a letter stating acceptance/acknowledgement of the incoming evaluation.
 
A district may accept an evaluation performed by a private provider conducted for non-educational purposes, but must draft a letter stating acceptance/acknowledgement of the incoming evaluation, which allows the district to utilize the existing evaluation through the expiration date of one (1) year from the date the evaluation, was conducted; after this time, a full evaluation must be performed. 

Therapy Prior Authorization for Extension of Benefits

Prior to Medicaid claiming for a student, the student’s primary care physician referral is required via the DMS-640 Medicaid form, annually. For prior authorization referrals offering ninety minutes or more per week, the completed DMS-640 must be sent to eQHealth Solutions for approval for extension of benefits. 
 
 

Therapist Credentials and Responsibilities

School-based performing therapists must have a valid Arkansas License and an active Medicaid Provider Number linked with the provider’s National Provider Identification (NPI) Number. 
 

For more information, please contact:

 
Dana Bennett, RN Northwest Regional Program Advisor
Arkansas Department of Education
Division of Elementary and Secondary Education
School Health Services
Office:  479-495-1469 
 
 
Rena McCone, Southern Regional Program Advisor
Arkansas Department of Education
Division of Elementary and Secondary Education
School Health Services
Office:  501-519-9279
 
 
Sarah Dover, Northeast Regional Program Advisor
Arkansas Department of Education
Division of Elementary and Secondary Education
School Health Services
Office: 501-951-0114
 
 
Gina Babbitt, RN, Central Regional Program Advisor
Arkansas Department of Education
Division of Elementary and Secondary Education
School Health Services
Office: 501-683-3604