Search

August 01, 2024

Outpatient therapy and chiropractic prior authorization requirements

Effective Sept. 1, 2024, we’ll require prior authorization for physical therapy (PT), occupational therapy (OT), speech therapy (ST) and chiropractic services delivered at multidisciplinary offices and outpatient hospital settings, excluding services in the home. This applies to UnitedHealthcare® Medicare Advantage nationally, excluding Dual Complete Special Needs Plans (SNP). Current prior authorization requirements in Arkansas, Georgia, South Carolina and New Jersey for outpatient therapies will continue as previously deployed.

Process

Prior authorization is not required for claims for the initial evaluation to be considered for reimbursement. However, a prior authorization is required for subsequent treatment visits. Health care providers are required to submit the initial evaluation results and the plan of care by completing an outpatient assessment form. 

We’ll review the prior authorization request for medical necessity using CMS Chapter 15 criteria, applicable LCDs and InterQual® criteria to render a determination. Medical necessity reviews are conducted by licensed medical professionals including physical therapists, occupational therapists and speech-language pathologists. The provider and patient will be notified of our medical necessity determination.

Affected procedures

Procedure codes impacted:

  • Outpatient therapies: 92507, 92508, 92526, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97799, G0283
  • Chiropractic services: 98940, 98941, 98942

Impacted plans

This affects the following UnitedHealthcare Medicare Advantage benefit plans:

  • Medicare Individual (including Chronic SNPs)
  • Medicare Group Retiree
  • UHCWest Medicare plans in Nevada, Oregon, Washington and Texas
  • UHCWest Medicare plans in Colorado will begin on Jan. 1, 2025
  • Excluded plans: UnitedHealthcare® Dual Complete plans, UnitedHealthcare® Nursing Home and UnitedHealthcare® Assisted Living Plans, Erickson Advantage, Preferred Care Network and Preferred Care Partners of Florida, UHCWest (California, Arizona), OptumCare, WellMed, Peoples Health Plan, Rocky Mountain Medicare Advantage plans

What you need to know

  • We’ve delegated the initial authorization and concurrent review processes for outpatient therapy services to Optum Health Solutions
  • We’ll use the criteria in our Medicare Advantage Prior Authorization Requirements to facilitate our outpatient therapy authorizations and concurrent reviews
  • Process changes begin Sept. 1, 2024
  • Initial evaluations do not require prior authorization
  • Inpatient and services in the home are excluded from this program

How to submit a request

You can submit a prior authorization request through the UnitedHealthcare Provider Portal:

  • Go to UHCprovider.com and click Sign In at the top-right corner
  • Enter your One Healthcare ID and password
  • In the menu, select Prior Authorizations
  • Scroll down to “Create a new notification or prior authorization request” and click Create New Submissions
  • Enter the required information and submit

If we don’t receive a prior authorization request within 10 days after starting the service, we may deny the claim and you won’t be able to balance bill members.

Resources

Coverage determination guidelines

Training

Questions?

If you have questions, please read our Skilled Nursing Facility, Rehabilitation and Long-Term – Medicare Advantage Coverage Summary or visit our Prior Authorization and Notification web page.

PCA-1-24-01100-Clinical-NN_06042024

Finding news icon

Discover more news

Personalized news icon

Get personalized news