Clarification of Prior Authorization Requirements for CPT Code 92526
Dear Provider Partners,
Meridian is providing clarification regarding prior authorization requirements for CPT code 92526, treatment of swallowing dysfunction and/or oral function for feeding.
When Prior Authorization Is Required
For Meridian Medicaid, prior authorization is required for CPT code 92526 only when all of the following apply:
- The service is provided as occupational therapy;
- The claim will be billed with modifier GO; and
- The member has reached the Medicaid limit of 36 therapy services in a calendar year.
When these conditions are met, authorization must be obtained through Evolent before services beyond the 36-service limit are provided.
When Prior Authorization Is Not Required
Prior authorization is not required for other uses of CPT code 92526. For example, authorization is not required when the service is provided as speech therapy rather than occupational therapy. Authorization is also not required when occupational therapy services have not exceeded the 36-service calendar-year limit.
Provider Guidance
Before rendering CPT code 92526 as occupational therapy beyond the 36-service limit, confirm the member’s therapy utilization and submit the authorization request to Evolent.
Please retain the authorization determination in the member’s record and include modifier GO when billing the occupational therapy service.
Meridian will continue to keep the provider community informed of any future changes to authorization requirements. Until additional notice is issued, providers should follow the guidance above for CPT code 92526.