UnitedHealthcare (UHC) has updated its Medicare Advantage (MA) prior authorization requirement for physical, speech and occupational therapy, and chiropractic services that became effective September 1, 2024. These updates and additional guidance, which are applicable to both individual and group retiree members, were made as a result of feedback from providers, as well as a coalition of outpatient therapy provider organizations in which AHCA/NCAL participates.
Additional Information Specific to AHCA/NCAL Members
With respect to nursing home residents: The UHC MA prior authorization policy and guidance, which applies to outpatient physical and occupational therapy, speech-language pathology, and chiropractic services, does not apply to institutionalized residents in a nursing facility. So, no prior authorization is required.
However, if an assisted living (AL) resident with UHC MA coverage needs these services, the relaxed UHC prior authorization policy would apply if the AL resident receives the services in an office, an outpatient hospital department (on or off-campus), an ambulatory surgical center, an independent clinic, or a comprehensive outpatient rehabilitation facility.
The key revised prior authorization policy that an AL resident may be subject to includes:
- The initial consultation still does not require prior authorization.
- For new authorization requests starting on or after January 13, 2025, up to six visits of a member’s initial plan of care will be covered without conducting a clinical review when the first six visits take place within eight weeks.
- Coverage of the initial consultation and up to six visits of a member’s requested plan of care within eight weeks will apply without a clinical review under any of the following circumstances:
- The member is new to your office.
- The member presents with a new condition.
- The member has had a gap in care of 90 or more days.
- Only plans of care requesting more than six visits or exceeding eight weeks will be assessed for medical necessity.
- Authorizations are subject to member eligibility and timely filing policy.
- Once the initial plan of care is complete, additional visits may be requested by submitting a new request for authorization.