Last modified: Aug. 14, 2024
Update: Additional information provided regarding place of service codes.
Effective Sept. 1, 2024, we’ll require prior authorization for the following services delivered in multidisciplinary offices and outpatient hospital settings, excluding services in the home:
Multidisciplinary practices may encompass settings where physical therapy, occupational therapy, speech therapy and chiropractic care are all provided within a single facility or office. Alternatively, they could refer to individual practices each specializing in a single discipline.
Prior authorization is required for the following place of service codes:
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 continues as previously deployed and will now include Medicare-covered chiropractic services.
Prior authorization is not required for claims for the initial evaluation to be considered for reimbursement. However, a prior authorization is required for the treatment plan which specifies the number of visits. Health care providers are required to submit the initial evaluation results and the plan of care by completing an outpatient assessment form. After the initial treatment plan is completed, if additional visits are needed, health care providers will need to submit prior authorization.
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.
Procedure codes impacted:
This affects the following UnitedHealthcare Medicare Advantage benefit plans:
You can submit a prior authorization request through the UnitedHealthcare Provider Portal:
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.
Coverage determination guidelines
Training
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-1-24-02507-Clinical-NN_08142024