Outpatient therapy and chiropractic prior authorization requirements

Last modified: Sept. 9, 2024
Update: Additional information provided regarding place of service codes and how to submit requests.

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:

Physical therapy (PT)
Occupational therapy (OT)
Speech therapy (ST)
Medicare-covered chiropractic services (when billed with the AT-modifier)

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:

11 Office
19 Off-Campus Outpatient Hospital
22 On-Campus Outpatient Hospital
24 Ambulatory Surgical Center
49 Independent Clinic
62 Comprehensive Outpatient Rehabilitation Facility

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.

Process

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.

Affected procedures

Procedure codes impacted:

Outpatient therapies: 92507, 92508, 92526, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97799, G0283
Chiropractic services (Medicare-covered): 98940, 98941, 98942 when billed with the AT-modifier

Impacted plans

This affects the following UnitedHealthcare Medicare Advantage benefit plans:

Medicare Individual (including Chronic SNPs)
Medicare Group Retiree
UHCWest Medicare plans in Nevada, Oregon, Washington and Texas
UHCWest Medicare plans in Colorado will begin on Jan. 1, 2025
Excluded plans: UnitedHealthcare® Dual Complete plans, UnitedHealthcare® Nursing Home and UnitedHealthcare® Assisted Living Plans, Erickson Advantage, Preferred Care Network and Preferred Care Partners of Florida, UHCWest (California, Arizona), OptumCare, WellMed, Peoples Health Plan, Rocky Mountain Medicare Advantage plans

What you need to know

We’ve delegated the initial authorization and concurrent review processes for outpatient therapy services to Optum Health Solutions
We’ll use the criteria in our Medicare Advantage Prior Authorization Requirements to facilitate our outpatient therapy authorizations and concurrent reviews
Process changes begin Sept. 1, 2024
Initial evaluations do not require prior authorization
Inpatient and services in the home are excluded from this program

How to submit a request

You can submit a prior authorization request through the UnitedHealthcare Provider Portal:

Go to UHCprovider.com and click Sign In at the top-right corner
Enter your One Healthcare ID and password
- New users who don’t have a One Healthcare ID: Visit UHCprovider.com/access to get started
In the menu, select Prior Authorizations
Scroll down to “Create a new prior authorization submission,” click “Select prior authorization type for submission” and then select “Physical Health”
Next click “Select plan type,” select “Medicare” and click “Continue”
Enter the required information and submit

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.