This article explores UnitedHealthcare's updated prior authorization policy for Medicare Advantage members, which simplifies access to therapy services like physical therapy, occupational therapy, and speech-language pathology. Starting January 13, 2025, the policy allows automatic coverage for up to six initial visits within eight weeks without a clinical review under specific conditions, reducing delays and improving patient outcomes. Learn how these changes streamline administrative tasks for providers while enhancing care continuity and efficiency.
UnitedHealthcare® has recently updated its prior authorization requirements for therapy and chiropractic services, effective from January 13, 2025. This change is particularly relevant for physical therapists, occupational therapists, and speech-language pathologists, as it simplifies the process and ensures timely care for Medicare Advantage Individual and Group Retiree members.
Key Changes in Prior Authorization
Under the new policy, providers must still submit a prior authorization request for the entire plan of care, including the full duration and number of visits requested. However, a significant update allows up to the first six visits of a member’s initial plan of care to be covered without a clinical review, provided these visits occur within eight weeks of the first date of service. This adjustment facilitates immediate treatment following the initial consultation, which is crucial for effective therapy outcomes.
Conditions for Automatic Coverage
The automatic coverage of the initial consultation and up to six visits within eight weeks applies under the following circumstances:
- The member is new to your clinic.
- The member presents with a new condition.
- The member has had a gap in care of 90 or more days.
These conditions ensure that members can receive prompt care without unnecessary delays, which is essential for conditions requiring immediate intervention, such as gait deviations, shoulder mobility issues, or speech and language impairments.
Streamlined Process for Therapists
For therapists, this policy change means that the initial six visits can commence immediately, allowing for a more efficient start to the treatment plan. Providers can request authorization up to 10 business days after the initial consultation, ensuring that the member’s care is not interrupted. This is particularly beneficial for addressing acute conditions that require swift intervention, such as post-stroke rehabilitation, post-surgical recovery, or acute musculoskeletal injuries.
Ensuring Continuity of Care
Once the initial plan of care is complete, additional visits may be requested through the standard authorization process via the Optum Provider Portal. This ensures that ongoing care is appropriately managed and that members continue to receive the necessary therapy services. Providers are encouraged to submit claims for care following the receipt of approved authorization to ensure seamless coverage.
Impact on Therapy Practices
This policy update is expected to have a positive impact on therapy practices by reducing administrative burdens and allowing therapists to focus more on patient care. By covering the initial visits without a clinical review, therapists can quickly address critical issues such as improving a patient’s ability to perform daily activities, enhancing mobility, and facilitating better communication skills.
Conclusion
The updated prior authorization requirements by UnitedHealthcare® represent a significant step towards improving access to therapy services for Medicare Advantage members. By allowing immediate coverage for the initial visits, therapists can provide timely and effective care, ultimately leading to better patient outcomes. Clinic owners and therapists should familiarize themselves with these changes to ensure they can take full advantage of the streamlined process and continue to deliver high-quality care to their patients.