Medicare Advantage: Updates to prior authorization requirement for outpatient therapy and chiropractic services

Based on feedback from providers, UnitedHealthcare has updated the prior authorization requirement for physical, speech and occupational therapy and chiropractic services that became effective Sept. 1, 2024, for UnitedHealthcare® Medicare Advantage individual and group retiree members.

Prior authorization updates

Providers must continue to submit a prior authorization request for the entire plan of care, including the full duration and number of visits requested. However, for new authorization requests starting on or after Jan. 13, 2025, up to the first 6 visits of a member’s initial plan of care will be covered without conducting a clinical review when the first 6 visits take place within 8 weeks of the first date of service.

Only care plans requesting more than 6 visits or care plans exceeding 8 weeks will be assessed for medical necessity. The initial consultation/evaluation still does not require prior authorization.

Criteria for services not requiring clinical review

Coverage of the initial consultation and up to 6 visits of a member’s requested plan of care within 8 weeks will apply without a clinical review under any of the following circumstances:

The member is new to your office
The member presents with a new condition
The member has had a gap in care of 90 or more days

Additional information

This change is being made to enable providers to begin treatment the same day as the member’s initial consultation, when clinically appropriate, and ensure additional care is provided promptly. No changes are needed to your current clinical submission process.
Authorization may be requested up to 10 business days after the member’s initial consultation. The member’s care may commence immediately. Up to the first 6 visits within 8 weeks will be covered regardless of the status of the authorization request.
Providers are encouraged to submit claims for care following receipt of approved authorization
Coverage is subject to confirmation of member eligibility
Once the initial plan of care is complete, additional visits may be requested by submitting a request for authorization

Please continue to follow the submission process through the UnitedHealthcare Provider Portal.

The Patient Summary Form will have additional language, as stated below:

Subject to eligibility verification and timely filing, UnitedHealthcare will cover up to six (6) visits, over up to eight (8) weeks under any of the following conditions on an initial submission:

The member is new to your office.
The member presents with a new condition.
The member has had a gap in care of 90 or more days.

Additionally, any treatment needs beyond the approved service levels will require a clinical submission for further review. Date extensions and modifications to this approval are not permitted.

When a prior authorization request is submitted, the following message(s) will appear:

Your request qualifies for coverage of up to six (6) visits, over up to eight (8) weeks pending member eligibility and timely filing. If more than six (6) visits or more than eight (8) weeks is requested, it will be determined based on your clinical review.