New Prior Authorization Rules for Outpatient Therapy and Chiropractic Services

Effective September 1, 2024, prior authorization will be needed for certain services provided in multidisciplinary offices and outpatient hospital settings. This doesn’t apply to services provided at home. The services requiring prior authorization include:

  • Physical therapy (PT)
  • Occupational therapy (OT)
  • Speech therapy (ST)
  • Medicare-covered chiropractic services (when billed with the AT-modifier)

Multidisciplinary practices are places where you can get physical therapy, occupational therapy, speech therapy, and chiropractic care all in one office or facility. Sometimes, they can also be individual offices that specialize in just one of these areas.

Starting soon, certain services will need prior authorization if they happen in specific places, including:

  • Office settings (code 11)
  • Off-campus outpatient hospitals (code 19)
  • On-campus outpatient hospitals (code 22)
  • Ambulatory surgical centers (code 24)
  • Independent clinics (code 49)
  • Comprehensive outpatient rehabilitation facilities (code 62)

This rule applies to UnitedHealthcare® Medicare Advantage plans across the country, except for Dual Complete Special Needs Plans (SNP). The existing rules for prior authorization in Arkansas, Georgia, South Carolina, and New Jersey will stay the same, and now Medicare-covered chiropractic services will also need prior authorization.

Process

Before starting treatment, no prior authorization is needed for the initial evaluation, so it can be reimbursed. However, once the treatment plan is made, which includes the number of visits, a prior authorization is required. Healthcare providers must submit the initial evaluation results and the treatment plan using an outpatient assessment form. If more visits are needed after the initial treatment, providers must get another prior authorization.

When a prior authorization request is made, it will be reviewed to see if the treatment is medically necessary. This review is done by licensed medical professionals, including physical therapists, occupational therapists, and speech-language pathologists, using specific criteria. Both the provider and the patient will be informed about the decision.

Affected Procedures

The procedure codes that need prior authorization include:

  • 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

Plans Affected

This update affects these UnitedHealthcare Medicare Advantage plans:

  • Medicare Individual plans (including Chronic SNPs)
  • Medicare Group Retiree plans
  • UHCWest Medicare plans in Nevada, Oregon, Washington, and Texas
  • UHCWest Medicare plans in Colorado starting January 1, 2025

Plans Not Affected

  • UnitedHealthcare® Dual Complete plans
  • UnitedHealthcare® Nursing Home and Assisted Living Plans
  • Erickson Advantage
  • Preferred Care Network and Preferred Care Partners of Florida
  • UHCWest in California and Arizona
  • OptumCare
  • WellMed
  • Peoples Health Plan
  • Rocky Mountain Medicare Advantage plans

What You Need to Know

  • Starting September 1, 2024, Optum Health Solutions will handle the approval process for outpatient therapy services.
  • They will use specific rules to decide on these approvals.
  • Initial evaluations don’t need prior approval.
  • Services provided in the hospital or at home are not included in this change.

How to Submit a Request

  • Go to UHCprovider.com and click “Sign In” at the top-right corner.
  • Enter your One Healthcare ID and password.
  • If you’re a new user without a One Healthcare ID, visit UHCprovider.com/access to get one.
  • Select “Prior Authorizations” from the menu.
  • Click “Create New Submissions” under “Create a new notification or prior authorization request.”
  • Fill in the required information and submit.

If a prior authorization request is not received within 10 days after starting the service, the claim might be denied and you won’t be able to charge the members extra.

 


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