Appeals for occupational therapy practices, built from your chart.
Appeals turn on functional limits in daily activities, goals tied to them, and why the care needs an occupational therapist. Ties each payer rule to the occupational profile, activity-level goals, skilled-intervention notes and standardized scores, for adults, hand therapy and pediatric caseloads.
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What the reviewer looks for.
These are the points a occupational therapy appeal has to prove. ClaimDoc checks each one against your record and names the page that proves it, or the document that is missing.
Evaluation with functional findings
An evaluation documents the diagnosis, the client's occupational performance and the limits in daily activities that therapy addresses, with objective or standardized findings.
Plan of care with measurable activity goals
A written plan of care states measurable goals tied to daily activities, and the type, frequency and duration of treatment.
Services needed an occupational therapist
The treatment notes show interventions (for example activity retraining, splinting, sensory or motor programs) that required the clinical judgment of an occupational therapist rather than routine practice.
Measurable progress
Re-measurement shows objective progress toward the goals, or skilled care needed to maintain function.
The records it asks for.
ClaimDoc asks only for what this denial needs, marks what you've uploaded, and says in a line why each one matters.
- Occupational therapy evaluationneededShows the baseline limits in daily activities and the standardized findings the plan is built on.
- Plan of care with the physician's or NPP's signature and dateneededMedicare and many plans require the certified plan to cover the denied dates.
- Treatment notes for the denied datesneededProve the skilled intervention delivered each day and its time.
- Progress reportsShow movement toward each goal.
- Standardized scores (QuickDASH, COPM, Sensory Profile, BOT-2)Scores make progress objective.
Denials it handles.
Plain words first. For each, what usually decides the appeal.
“Not medically necessary”
Functional limits in daily activities, goals tied to them, and skilled intervention in the notes.
“Visit limit reached”
The plan's exception path or a documented change in the client's condition.
“Over the yearly therapy limit”
Medicare: the KX modifier with documentation that the therapy is still medically necessary.
The rules ClaimDoc holds for occupational therapy.
Stored word for word
- Medicare Benefit Policy Manual, Chapter 15, §220–230 (Outpatient therapy)
- MLN905365: Complying with Outpatient Rehabilitation Therapy Documentation Requirements
- CMS Therapy Services: KX modifier threshold
- Jimmo v. Sebelius settlement: skilled maintenance therapy
- Medicare Claims Processing Manual, Chapter 5 (Part B outpatient rehabilitation), §10–20
Medicare coverage on file
4 local and national coverage documents from CMS, across 2 Medicare contractors. When a Medicare denial rests on one, the letter names the one for your contractor and asks which provisions applied.
Payers, by how much is known
- Aetna
- Original Medicare (Part A outpatient and Part B)
- Aetna Medicare Advantage
- Alignment Healthcare
- Cigna Medicare Advantage
- Clover Health
- Devoted Health
- Humana
- SCAN Health Plan
- UnitedHealthcare
Tested, not promised.
Each of these ran from upload to a finished, verified packet on synthetic records, and every factual sentence traced to a page of the record or a stored policy.
- AetnaContinued hand therapy after a wrist fracture appealed on Aetna's form; 14 of 14 sentences sourced
Send back proof.
Free to start, no card. HIPAA compliant, with a business associate agreement for every clinic.