TX HHS Form 2464. Rehabilitative Services Request

Form 2464 is a Texas Health and Human Services rehabilitative services request used by nursing facilities and therapy providers to request authorization for physical, occupational, or speech therapy services for Medicaid recipients. The form documents medical eligibility, current functional status, and measurable therapy goals to determine whether rehabilitative therapy is appropriate and authorized under Medicaid program rules.

Purpose of Form 2464

The primary purpose of Form 2464 is to request approval for rehabilitative therapy services in a nursing facility setting. It allows HHSC or its contractors to evaluate whether therapy services are medically necessary, goal-oriented, and likely to result in measurable improvement within a defined period.

This form is also used to distinguish rehabilitative therapy from services that fall outside Medicaid coverage or that require a different authorization pathway.

When This Form Must Be Used

Form 2464 must be submitted when a provider is requesting rehabilitative therapy services for a Medicaid recipient in a nursing facility. Common situations include:

• An initial request for physical, occupational, or speech therapy
• A restarted therapy episode requiring a new evaluation
• A recertification review for continued therapy services

The form must not be used if the recipient has a qualifying diagnosis such as intellectual disability, cerebral palsy, developmental delay, or a closed head injury before age 22. In those cases, Form 2465 (Specialized Services Request) is required instead.

Who Is Authorized to Complete the Form

Form 2464 is typically completed by licensed therapy professionals or nursing facility staff working in coordination with the therapy department. This includes:

• Physical therapists (PT)
• Occupational therapists (OT)
• Speech-language pathologists (ST)
• Nursing facility administrative or therapy coordination staff

The form must be complete and legible before submission, or it will not be reviewed.

Explanation of Key Sections

Eligibility Screening Question

The opening question determines whether the recipient has a diagnosis that requires specialized services authorization. A “Yes” response stops the process and redirects the provider to Form 2465.

Type of Therapy and Evaluation Status

This section identifies the type of therapy requested and whether the request is new, restarted, or a recertification. Selecting the correct option determines what supporting documentation must be submitted.

Recipient Identification and Medical Information

This section captures identifying details, Medicaid information, primary and secondary diagnoses, and dates of diagnosis. Accuracy here is critical for eligibility and claims matching.

Nursing Facility and Provider Information

Details about the nursing facility, admission dates, provider numbers, and contact information are used to verify service location and billing responsibility.

Functional Status at Present

This section requires measurable, objective descriptions of the recipient’s current functional limitations. Vague descriptions are commonly rejected.

Thirty-Day Goals

Therapy goals must be specific, measurable, and achievable within 30 days. These goals are used to assess medical necessity and progress.

Orientation and Ability to Participate

This section documents the recipient’s cognitive and physical ability to actively participate in therapy, which is a requirement for rehabilitative services.

Plan of Care and Discharge Planning

The therapist must establish a clear plan of care for staff to follow and outline discharge expectations. Continued therapy requires significant measurable progress.

Practical Tips for Completing Form 2464

• Use objective, measurable language for functional status and goals.
• Confirm the diagnosis does not require Form 2465 before submitting.
• Ensure all required fields are complete and legible.
• Match therapy goals to documented functional deficits.
• Submit required evaluations when requesting new or restarted services.

Common Mistakes to Avoid

• Submitting Form 2464 for recipients who require specialized services
• Using vague or non-measurable therapy goals
• Leaving required fields incomplete
• Requesting non-covered services such as splinting or wound care
• Assuming authorization guarantees payment

Legal and Program Context

Form 2464 is governed by Texas Medicaid rehabilitative services rules. State policy limits coverage to therapies that demonstrate medical necessity and measurable improvement. Services such as range of motion exercises, splinting, positioning, wound care, and staff or family training alone are not covered under this program.

Submitting incomplete or inaccurate information may delay authorization or result in denial of services.

Real-Life Examples of Use

• A nursing facility requests physical therapy after a resident experiences a decline following hospitalization.
• An occupational therapist restarts therapy services after a documented change in functional ability.
• A speech therapist submits measurable goals for a short-term rehabilitative episode.

Documents Commonly Submitted with This Form

• Initial therapy evaluations
• Medical records supporting diagnoses
• Prior therapy discharge summaries
• Nursing facility admission records

Frequently Asked Questions

Is Form 2464 required for all therapy services?

It is required for rehabilitative therapy services under this Medicaid program.

What happens if the form is incomplete?

Incomplete forms are not reviewed.

Does authorization guarantee payment?

No, authorization does not guarantee payment.

Can this form be used for long-term maintenance therapy?

No, services must show measurable improvement.

When is Form 2465 required instead?

When the recipient has certain qualifying diagnoses before age 22.

How long do approved services last?

Approval is based on short-term goals and progress reviews.

Related Forms

• Form 2465 – Specialized Services Request
• Therapy Evaluation Reports
• Restorative Nursing Care Plans

Form Details

• Form Name: Rehabilitative Services Request
• Form Number: 2464
• Program: Texas Medicaid Rehabilitative Services
• State: Texas
• Revision Date: November 2010