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Provider Notice Issued 06/16/2022

Date:   June 16, 2022

To:       Enrolled Occupational Therapists

Re:      Occupational Therapy Evaluation Rate Increases Effective March 1, 2022


This notice announces new rates for occupational therapy (OT) evaluation services billed on the 837P claim transaction. The rates apply to claims billed under the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois managed care plans. The rates do not apply to OT services billed on the 837I claim format by home health agencies or hospitals.

The OT evaluation rates are being increased as a result of a rate analysis performed under the Williams and Colbert Consent Decrees. The new rates for the procedure codes identified below apply to both children and adult patients. New rates are effective with dates of service beginning March 1, 2022, as follows:

ServiceProcedure CodeModifierUnit Rate
Occupational Therapy Evaluation Low Complexity97165GO$16.19
Occupational Therapy Evaluation Moderate Complexity97166GO$17.19
Occupational Therapy Evaluation High Complexity97167GO$17.75

The 2.7% rate reduction mandated by the SMART Act is already included in the above rates.

Providers will need to submit replacement claims (bill type/claim frequency "7") if services with dates of service on and after March 1, 2022, were adjudicated prior to finalization of rate updates. The Department will accept electronic replacement claims submitted through MEDI or via 837P files if submitted within 12 months from the original paid voucher date. Please refer to the replacement claim instructions found in the Chapter 300 Companion Guide for 837P transactions. 

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims or to the applicable managed care plan.

Kelly Cunningham, Administrator
Division of Medical Programs



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