Medicare new prior authorization requirement that includes clinical submission

Effective Feb. 1, 2022, UnitedHealthcare will require you to obtain prior authorization for Physical Therapy (PT), Occupational Therapy (OT) and Speech therapy (ST) services delivered at multi-disciplinary offices and outpatient hospital settings in Arkansas, Georgia, New Jersey and South Carolina. These prior authorization requirements apply to patients new to therapy and those who are currently receiving therapy.

Note: The initial evaluation for your patient does NOT require prior authorization. However, in order to receive reimbursement for the initial evaluation, the results from the initial evaluation, (the patient assessment form) must be submitted for review. The initial patient evaluation will be used to assist in the request for follow-up treatment which does require prior authorization.

See the list of CPT® codes for affected services.

How do I request authorization?
For dates of service on or after Feb. 1, 2022,
use the Prior Authorization and Notification tool, sign in and select MBM Now to submit clinical information and your patient evaluation to request authorization for your planned PT, OT and ST services after the initial evaluation.

Medical necessity reviews are conducted by licensed medical professionals, including physical therapists, occupational therapists and speech-language pathologists. You and your patient will be notified of our review results.

Will these requirements affect claims? 
Yes. If you don’t obtain a prior authorization online before performing a PT, OT or ST procedure, your claim for that service will be denied and the patient cannot be billed for the service.

Review the medical necessity guidelines used to help facilitate the medical necessity determinations for these services.

Outpatient rehabilitation therapy physical therapy, occupational therapy and speech-language pathology services conditions of coverage

Outpatient therapy services are covered in accordance with certain conditions as outlined in the Medicare Benefit Policy Manual, Chapter 15, §220.1 – Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services (accessed April 8, 2021).

Contact Optum Provider Services at 800-873-4575 if you have any questions.

CPT® is a registered trademark of the American Medical Association.