Kansas, North Carolina and Virginia Medicaid: Outpatient 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 age of 3 and older in Kansas, North Carolina and Virginia. In North Carolina, this is also an expansion to members aged 21 and older.

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

• Each requested visit requires prior authorization
• 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. A prior authorization request must still be submitted for the 6 visits.
• Only care plans with more than 6 visits requested for more than 8 weeks will be assessed for medical necessity
• Authorization requests can be submitted up to 2 business days following the first date of service. Authorizations, when issued, 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.

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

North Carolina: Please note these changes impact all patients requiring PT, OT and ST services, both those under and over the age of 21.

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
• Kansas only- Pediatric Care Network and LTSS

Resources

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