UHC Continues Refinement of Prior Authorization Policy

In another update to a process that began last summer, UnitedHealthcare has implemented changes to its prior authorization requirements in certain Medicare Advantage plans for PT treatment visits following an initial evaluation when services are provided in office and outpatient hospital settings. As a result of continued APTA advocacy and communication with UHC, the insurer contacted APTA staff in March with the stated changes, indicating they are made to help ensure timely provision of services to patients.

The latest revisions include:

Technology updates that provide therapists with real-time coverage information. When patient information is entered into the submission portal, real-time member eligibility information will be available so that providers can begin treatment immediately, including the same day as the initial consultation, when clinically appropriate.
A shortened submission form is now available in the provider portal for initial prior authorization requests of six or fewer visits over eight weeks, eliminating the need for additional documentation. UHC reminds providers that a prior authorization request is still required for all visits within the entire plan of care, including the full duration and number of visits. If that number of visits is six or fewer, providers can use the new shorter form. For subsequent requests beyond the initial plan of care, the provider will need to submit for a new authorization.
Upon completing the submission process, real-time coverage for initial requests of six visits over eight weeks will be confirmed and visible in the portal the same day. An initial request for prior authorization applies to a patient who is new to the provider, has a new condition, or has had a gap in care of 90 days or more.
If more than six visits are requested, the first six will be immediately covered, and the remaining visits will be reviewed for medical necessity.

In its communications with APTA, UHC said there would not be a published statement or messaging to providers with this new information. Providers are directed to this FAQ for more information: Changes to prior authorization requirement for Medicare Advantage outpatient therapy services - UnitedHealthcare Medicare Advantage plans.

As APTA has reported earlier, the association’s advocacy brought other changes to UnitedHealthcare policies that will somewhat ease certain prior authorization requirements. These changes are outlined below.

As of Jan. 13, UHC allows up to six follow-up visits after an initial evaluation without requiring a clinical review. Previously, a clinical review was required before any follow-up visits could occur, which APTA strongly argued would delay needed services and hinder effective care. In announcing the change, UHC said that "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."

Provisions of the Policy

Coverage for the six visits applies under any one of the following circumstances:

The patient is new to the PT's office.
The patient presents with a new condition.
The patient has had a gap in care of 90 or more days.

Providers must continue to submit a prior authorization request for the entire plan of care, including the full duration and number of visits requested. In addition, the six visits must occur within eight weeks of the initial evaluation. Only care plans requesting more than six visits or care plans exceeding eight weeks will be assessed for medical necessity. The initial consultation/evaluation still does not require prior authorization.

Additionally, UHC provided the following 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 that additional care is provided promptly. No changes are needed to the current clinical submission process.
Authorization for additional visits may be requested up to 10 business days after the patient’s initial consultation. The patient’s care may commence immediately. Up to the first six visits within eight 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.