Medicare Advantage: Prior authorization resources for outpatient therapy and chiropractic services

On Sept. 1, 2024, we began requiring prior authorization for physical, occupational, speech therapy and chiropractic services for UnitedHealthcare® Medicare Advantage members. Optum Physical Health has been delegated to review the prior authorization request for medical necessity using CMS Chapter 15 criteria, applicable local coverage determinations (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.

Reviews are conducted after the member’s initial consultation and evaluation and consider the specific circumstances of the individual member to approve a course of treatment supported by the clinical evidence.

Note: Treatment can begin the same day as the member’s evaluation if you wish to do so, as authorizations, when issued, will cover dates retroactive to the date of the evaluation. You can submit an authorization up to 10 business days (14 calendar days) after the date of service, and authorizations, when issued, will be retroactive to the date of the evaluation.

Exclusions

The below plans and provider types are not required to submit for authorization:

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

Note: OptumCare and WellMed contracted providers, please refer to the number on member ID card for prior authorization instructions.

Chiropractic care services

Routine (maintenance) chiropractic services will not require prior authorization. Only traditional Medicare-covered chiropractic services (which covers only manual manipulation of the spine to correct subluxation) require prior authorization.

Per CMS, traditional Medicare-covered chiropractic services are identified by an AT modifier. Please refer to cms.gov for additional information. The chiropractor will need to bill with the AT modifier for traditional Medicare services.

Skilled nursing facility services

For skilled nursing facility providers, the bill type defines the place of service, which determines if a prior authorization needs to be submitted. For example, bill type 22X or 24X for a Part B Nursing home would not need to submit prior authorization.

Place-of-service codes

Prior authorization is required for services rendered in the following places of service. If your claim is submitted indicating procedures were performed at one of these places of service and an authorization has not been obtained, your claim will be denied:

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

Note: Inpatient therapy services and services rendered in the home are excluded from the prior authorization requirement.

This includes services rendered by therapists and chiropractors who operate their own practices or who practice in the same office, such as a physical therapist and an occupational therapist who practice together and services provided in hospital-owned therapy and chiropractic offices.

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
- New users who don’t have a One Healthcare ID: Visit UHCprovider.com/access to get started
In the menu, select Prior Authorizations
Scroll down to “Create a new prior authorization submission,” click “Select prior authorization type for submission” and then select “Physical Health”
Next click “Select plan type,” select “Medicare” and click “Continue”
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.

Claims submission process

To submit a claim:

Ensure you have received an authorization prior to submitting the therapy claim to UnitedHealthcare to help avoid denials for lack of an authorization
The Clinical Submission Number or Service Reference Number (SRN#) is acceptable to submit on the claim form
If you received an approved authorization after a claim’s submission, then you can resubmit the claim for payment