New Prior Authorization Rules for Outpatient Therapy and Chiropractic Services

Prior authorization is now required for physical, occupational, speech therapy, and chiropractic care provided in offices or outpatient hospital settings. This applies to UnitedHealthcare® Medicare Advantage members. Home-based services are not included.

What’s New?

Providers must obtain prior authorization for PT, OT, ST, and Medicare-covered chiropractic services for UnitedHealthcare Medicare Advantage members. This applies to services in office or outpatient hospital settings, but not home settings.

• The initial evaluation does not need prior authorization.
• First 6 Visits: Up to 6 visits within 8 weeks of a new plan of care are covered without a clinical review under these conditions:
  • The member is new to your office.
  • The member has a new condition.
  • There’s been a 90-day or longer gap in care.
  • Note: You must still submit a prior authorization request for these 6 visits.
• More Than 6 Visits or 8 Weeks: For plans with more than 6 visits or 8 weeks, CMS guidelines, InterQual criteria, and insight from licensed professionals (like chiropractors, physical therapists, occupational therapists, speech-language pathologists) will be used to determine if the care is medically necessary.
• Additional Visits: Providers must submit a fresh prior authorization form after the patients have been treated for six visits.

For a comprehensive overview of the requirements that began Sept. 1, 2024, see the Advance Notification and Clinical Submission Requirements. 

Why Does This Matter?

• Claims Impact: Without prior authorization, claims may be denied, and providers cannot bill the member (balance billing is not allowed).
• Timely Submission: Prior authorization requests must be submitted within 10 business days (14 calendar days) of starting services to avoid claim denials.
• Incomplete Requests: If a request lacks required information, UnitedHealthcare will contact the provider. If the information isn’t provided, the request may be denied.

Who Is Affected?

Plans Requiring Prior Authorization:

• Medicare Individual plans (including Chronic Special Needs Plans)
• Medicare Group Retiree plans
• UHCWest Medicare plans in Nevada, Oregon, Washington, and Texas

Plans Excluded:

• Out-of-network providers
• UnitedHealthcare Dual Complete (including Optum at Home)
• UnitedHealthcare Nursing Home and Assisted Living Plans
• Specific UHCWest plans in California and Arizona
• Erickson Advantage
• Peoples Health Plans
• Preferred Care Network and Preferred Care Partners of Florida
• Rocky Mountain Medicare Advantage Plans

Services Excluded:

• Inpatient therapy and therapy in home settings (follows existing Home Health prior authorization rules).
• Routine chiropractic services (a supplemental benefit not covered by Medicare, e.g., for pain relief or nausea) do not require prior authorization. However, Medicare-covered chiropractic services (manual spine manipulation to correct subluxation, billed with the AT-modifier) do require prior authorization.

Affected Services and Codes

These requirements only cover special outpatient therapy and Medicare-covered chiropractic services:

• 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 (Medicare-covered): 98940, 98941, 98942 when billed with the AT-modifier

Places of Service Requiring Authorization:

• Office (Code 11)
• Off-Campus Outpatient Hospital (Code 19)
• On-Campus Outpatient Hospital (Code 22)
• Ambulatory Surgical Center (Code 24)
• Independent Clinic (Code 49)
• Comprehensive Outpatient Rehabilitation Facility (Code 62)

How to Comply

1. Submit Prior Authorization:
   • Use the UnitedHealthcare Provider Portal (select “Submission & Status” under “PT, OT, ST Outpatient Therapy Transactions”).
   • Include the initial evaluation results and the full plan of care (duration and number of visits).
   • The treating therapy or chiropractic provider should submit the request.
2. Billing:
   • Use appropriate CPT codes with revenue codes to ensure proper claim processing.
   • Submit claims after receiving authorization to avoid denials.
3. Check Status:
   • Visit the Optum Physical Health webpage and use the activity center’s “Check Status” link to track submissions.
   • Once complete, you’ll receive a summary and determination letter.
4. Appeals:
   • The Notice of Determination that is sent out following a denial will contain appeal instructions for providers and members.

Frequently Asked Questions

1. Do ongoing therapy patients need prior authorization?
   Yes, all therapy and Medicare-covered chiropractic services require prior authorization, but the first 6 visits within 8 weeks for new patients, new conditions, or after a 90-day gap are covered without a clinical review.
2. Can I start treatment on the same day as the evaluation? Yes, treatment can begin the same day, and up to 6 visits are covered without review, but you must submit a prior authorization request.
3. What if I need more than 6 visits? Submit a new prior authorization request for additional visits, which will be reviewed for medical necessity.
4. What happens if I don’t submit prior authorization? Claims may be denied, and you cannot bill the member.
5. Does this apply to multidisciplinary practices? Yes, practices offering PT, OT, ST, or chiropractic care (together or separately) must follow these rules for the listed place-of-service codes.
6. What about Skilled Nursing Facilities (SNFs)? SNFs billing with Part B bill types (e.g., 22X or 24X) do not need prior authorization.

Key Takeaways

• Act Fast: Submit prior authorization requests within 10 business days to avoid claim denials.
• Use the Portal: All requests must go through the UnitedHealthcare Provider Portal.
• Know the Rules: Initial evaluations are covered without prior authorization, and up to 6 visits within 8 weeks are covered without review for eligible cases.
• Stay Compliant: Ensure proper CPT and revenue codes are used to avoid claim issues.

For full details, visit UHCprovider.com or contact UnitedHealthcare/Optum for support.

• Providers contracted with UnitedHealthcare: 888-676-7768
• Providers contracted with Optum: 800-873-4575

This update ensures providers can navigate the new requirements while continuing to deliver quality care to Medicare Advantage members.