This information pertains solely to our practice at Pediatric Building Blocks. 

Referrals for Occupational Therapy

In the realm of private therapy referrals generally come in two ways, concerned parents or concerned care providers.  Parents often get information from other parents, literature, or the internet, and then contact our office seeking help for a suspected problem.  Sometimes they have been directed to us by a day care provider, teacher or other professional who has noticed something unusual. 

Physician referrals are only needed if families intend to charge their insurance company.  If this is your intention, call your Insurance carrier to determine IF they cover this service, under what circumstances, and what is required for referral.  Generally all insurance companies require a referral from a physician, complete with a diagnosis code.  Insurance companies tend to be very particular about which diagnosis is used, in example a diagnosis of Autism may be rejected, but a diagnosis of Apraxia or Dyspraxia will be accepted. Often there are limits to the number of visits, and types of treatment that are paid for. 

Many companies will not pay for an assessment, but if a need is identified they will pay for services.    Insurance billing is normally done on a "HCFA 1500" form, which requires the physicians identification number, care providers credential or license number. CPT codes for treatment are required and again companies are finicky as to which codes result in payment and which do not. 

In the academic realm, referrals can be initiated by either a parent or staff member.  Parents may make a written request of their school district for referral to special education when they feel their child has "a suspected area of deficit."  A written request is required by 5 C.C.R. Sec. 3021(a). Once the school district has received this written request, they have 15 calendar days (excluding days between school sessions, or vacation time in excess of  five days) to develop an Assessment Plan and submit it to the parent for approval and permission to conduct specific assessments indicating by a parental signature on the assessment plan..  The assessments must be completed, with written report of results, submitted to parents five days prior to and Individual Educational Plan (IEP) meeting for the child within 50 days from the date of the signed assessment plan (again excluding days between school sessions, or vacation time in excess of  five days.)  Once an IEP is completed is expected that it will be implemented immediately following the meeting.

Often parents will obtain a prescription from their pediatrician for services and present this to their school district during an IEP meeting or as part of the referral request.  AB3632 (CA. Gov. Code Sec. 7575(b) requires the physician provide a written report which includes the following: a diagnosis, treatment goals and objectives, the basis for determining goals and objectives, with expected outcome of treatment.  The relationship of the medical condition to the child's need for special education and related services, and any other relevant medical records.  Generally if a child has a medical need for therapy services they are served by California Children's Services (CCS) or other medical facility.  School districts are NOT responsible for medically necessary therapy, unless the IEP team determines that services are necessary for the child to benefit from educational instruction.  When there is a disagreement between a private physician and the school district, fair hearing proceedings may be necessary to determine if the child needs services for academic benefit.

 An excellent resource for parents who are approaching their schools with requests for services is the handbook, "Special Education Rights and Responsibilities", Written by: Community Alliance for Special Education (CASE) and Protection and Advocacy, Inc. (PAI) ©1992 02/00 Revised.  This booklet is reasonably priced and available from by contacting: CASE 1500 Howard Street, San Francisco, CA 94103. (415) 431-2285.