North Carolina and Virginia Medicaid: Physical therapy, speech therapy and occupational therapy services

Effective Nov. 1, 2025, UnitedHealthcare will require health care providers to obtain prior authorization for physical therapy (PT), occupational therapy (OT) and speech therapy (ST) services for UnitedHealthcare Community Plan members in North Carolina and Virginia. In North Carolina, this is an expansion to members over 21 years of age.

For North Carolina, the changes below will apply to members both under and over 21 years of age.

Prior authorization is required for the entire plan of care, excluding the initial evaluation codes, for all outpatient therapy services (PT, ST, OT). Please note the following important requirements:

• 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 occur within 8 weeks of the first date of service. A prior authorization request must still be submitted for the 6 visits.
• Only care plans requesting more than 6 visits for more than 8 weeks will be assessed for medical necessity.
• Authorization requests may be submitted up to 2 business days following the first date of service. When issued, timely authorizations will be retroactive to the date of the request.

These prior authorization requirements apply to patients new to therapy and those who are currently receiving therapy. 

• For North Carolina, patients that are under 21 and already have an authorization in place, a new authorization is not required. You can continue to utilize the current authorizations and submit for ongoing care when needed. 

Prior authorizations can be submitted beginning Oct. 1, 2025 for dates of service after on or after Nov. 1, 2025.

Additional Information

For patients currently receiving care, submit treatment plans for dates of service on or after Nov. 1, 2025, for medical necessity review. A prior authorization request must still be submitted to ensure claims are paid. The following documentation is required when submitting a prior authorization request for physical, speech, and occupational therapy services:

• Signed referral obtained at the time of the evaluation
• Current evaluation report and plan of care
• Current progress report or the member’s most recent daily treatment notes

To submit a prior authorization

You can submit your prior authorization request using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

The following are excluded from the new requirement.

• UnitedHealthcare® Dual Complete plans
• Members under 3 years of age

Resources

Details on exclusions, impacted CPT® codes, clinical examples and the authorization and claims submission process are included in our program FAQ.