UHC Medicare Advantage plans will require prior authorization for outpatient PT and OT for DOS on and after September 1, 2024.
The following is a link to the UHC announcement: https://www.uhcprovider.com/en/resource-library/news/2024/outpatient-therapy-chiropractic-prior-auth.html?cid=em-providernews-2024nnb3-Aug24
Requirements. Following an initial evaluation, outpatient PT/OT must be authorized for patients new to therapy and those who are currently receiving therapy. For requirements starting Sept. 1, 2024, see the Advance Notification and Clinical Submission Requirements.
Process. Prior authorization is not required for the initial evaluation but is required for subsequent treatment visits. As part of the authorization process, providers are required to submit the initial evaluation results and the care plan. Providers should use the UnitedHealthcare Provider Portal to request prior authorizations.
FAQS
Will these prior authorization requirements apply to patients who are already receiving therapy services? Yes. All PT/OT received on or after Sept. 1, 2024, requires prior authorization.
How does a provider request authorization? Providers should use the UnitedHealthcare Provider Portal to request prior authorization. Sign in and select “Submission & Status” under “PT, OT, ST Outpatient Therapy Transactions” to submit clinical information and request authorization for the planned PT or OT.
If I only complete an initial evaluation, will I be paid? Yes. You can submit a claim with the appropriate initial evaluation code. Prior authorization is not required for the initial evaluation.
What if the patient needs additional therapy visits after the initially authorized set of therapy visits has been approved and provided? If additional visits are needed, you will need to submit a new prior authorization request to obtain approval for the additional visits.
What happens if prior authorization is not requested? If UHC does not receive a prior authorization request within 10 days after starting the service, it may deny the claim and providers will not be able to balance bill patients.
What happens if an authorization is submitted with incomplete information? If an authorization request is submitted with incomplete information, the Optum Utilization Management (UM) team will try to reach out to the submitting provider to obtain the necessary information. If the provider submits the appropriate information within the required time frame, the request will be reviewed according to the UM process. If the submitting provider does not submit the required information, an incomplete request may be denied.
What happens if a provider wants to appeal a denial? If the authorization request is denied, appeals documentation will be included in the patient and provider Notice of Determination letter.
What is the contact information if providers have questions?
Providers contracted with UnitedHealthcare: 888-676-7768
Providers contracted with Optum: 800-873-4575
