New Jersey: Medicaid prior authorization requirements for certain therapy services

Effective Oct. 1, 2021, we’ll require prior authorization for all occupational therapy (OT), physical therapy (PT) and speech therapy (ST) services for UnitedHealthcare Community Plan of New Jersey members.

Prior authorization requirements

  • View the full list of the codes that require prior authorization
  • Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services, excluding emergency or urgent care
  • These requirements will apply whether a member is new to therapy or will continue receiving therapy
  • We’ll deny claims if prior authorization is not on file before the date of service, and you won’t be able to balance bill the member
  • Prior authorization isn’t required for emergency or urgent services

Medical necessity review

When you submit a prior authorization request starting Oct. 1, 2021, we’ll review your request for medical necessity. We’ll provide an authorization if appropriate and send that determination to you and the member.

Reviewing your requests before the effective date

We’d like to help you get ready by offering a review for your patients who are or will start receiving therapy services before the prior authorization requirement effective date. Starting 30 days before the effective date, you can submit the patient information using the Prior Authorization and Notification tool at UHCprovider.com/paan. We’ll let you know if your request meets the Speech Language Pathology Services or Outpatient Physical and Occupational Therapy coverage determination guidelines.

If the review shows that the request meets the coverage determination guidelines, we’ll give you an authorization number. With an authorization number, you won’t have to resubmit a request for that initial prior authorization.

If the review shows that the request wouldn’t be approved under the coverage determination guidelines, we’ll give you more information about our decision. You may resubmit for review with more information.

Questions?

Please contact us at 888-362-3368. For Optum contracting and credentialing questions, contact Optum at 800-873-4575.

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