Outpatient therapies prior authorization program for Medicare Advantage expanding to Arizona, Colorado, and Oklahoma

Beginning July 1, 2025, UnitedHealthcare will expand the current prior authorization requirement for physical, speech and occupational therapy (PT, ST and OT) and traditional Medicare chiropractic services (as identified by the AT modifier) to include UnitedHealthcare® Medicare Advantage individual and group retiree plan members in specific plans. Impacted plans in Arizona, Colorado, and Oklahoma are listed in this document.

This prior authorization program began Sept. 1, 2024, in all other states. This expansion creates more consistency for your team in treating UnitedHealthcare® Medicare Advantage members.

What you need to know

With this expansion, all contracted providers will be required to submit prior authorizations. You can start submitting prior authorization beginning June 1, 2025, for the following affected states:

• Arizona
• Colorado
• Oklahoma

Prior authorizations can be submitted beginning June 1, 2025.

Program summary

Prior authorization should be submitted after the initial evaluation. It is required for the entire plan of care, including the full duration and number of visits requested, for all outpatient therapy (PT, ST, OT) and chiropractic services. 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 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 requesting more than 6 visits or care plans exceeding 8 weeks will be assessed for medical necessity
• The initial consultation/evaluation still does not require prior authorization, any additional care after the evaluation does require authorization
• Authorization requests can be submitted up to 10 business days (14 calendar days) following the first date of service. Authorizations, when issued, will be retroactive to the date of the request.

Which plans are excluded from the new requirement?

• Out-of-Network providers
• UnitedHealthcare® Dual Complete plans
• UnitedHealthcare Nursing Home and UnitedHealthcare Assisted Living Plans
• UHCWest (specific plans in California and Arizona)
• Erickson Advantage
• Peoples Health Plans
• Preferred Care Network and Preferred Care Partners of Florida
• Rocky Mountain Medicare Advantage Plans

Resources

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

• Information on how to submit prior authorizations online
• Prior authorization changes for outpatient therapy services FAQ

Questions?

If you have questions, please read our Skilled Nursing Facility, Rehabilitation, and Long-Term Acute Care Hospital – UnitedHealthcare® Medicare Advantage Medical Policy or visit our Prior Authorization and Notification web page. You can also call 800-873-4575.

OptumCare and WellMed contracted providers, please refer to the number on member ID card for prior authorization instructions.