UnitedHealthcare Announces Broad Prior Authorization Requirements for Therapy and Chiropractic Services Under Its Medicare Advantage Plans

September 9, 2024

Update: January 23, 2025

On January 8, 2025, United Healthcare (UHC) announced updates to its Medicare Advantage (MA) prior authorization process. UHC claims the changes—which became effective January 13, 2025—reflect stakeholder feedback. But ASHA is concerned that these changes will not reduce clinicians’ administrative burden or improve patient access to care—and UHC’s prior authorization policy may not align with federal Medicare rules that govern the administration of the MA benefit.

UHC notes that the overall prior authorization process will not change. This means prior authorization requests for the full plan of care must be submitted via the UHC portal for all MA patients needing physical and occupational therapy, speech-language pathology, and chiropractic services. However, for new patients or existing patients presenting with a new condition or with a “gap in care of 90 or more days,” up to six visits provided within eight weeks will be approved without a clinical review. However, UHC could conduct a post-payment audit and determine the visits did not meet its coverage criteria, reinforcing that payment is not guaranteed.

For example, if an SLP submits a prior authorization request for four visits over four weeks, all four visits should be approved without additional review. However, if an SLP submits a request for 12 visits over 12 weeks, only six visits provided within the first eight weeks will be approved without a clinical review. The remaining six visits will be subject to a clinical review. ASHA is concerned this could continue to cause delays and gaps in care.

While this change may allow patients to receive some care more quickly, it does not address the underlying problems associated with the prior authorization submission process or challenges to the clinical judgment of the treating therapist. It also does not address that UHC’s prior authorization process conflicts with existing Medicare regulations on the use of utilization management techniques by MA plan sponsors. ASHA will continue its advocacy with both UHC and the Centers for Medicare & Medicaid Services to address these concerns.

Update: November 5, 2024

Since UHC rolled out its prior authorization policy, ASHA, the American Occupational Therapy Association, and the American Physical Therapy Association have met with UHC representatives three times to express our concerns about the policy and to request an end to prior authorization for these plans. Unfortunately, UHC has not agreed to rescind its policy and chose to expand the prior authorization program to Medicaid managed care plans effective October 1, 2024. Given that UHC will not be pausing or ending this program in the immediate future, ASHA has developed some resources to help you navigate this challenging time.

ASHA remains in contact with UHC and the Centers for Medicare & Medicaid Services (CMS) to raise concerns about this program. We will keep members posted on updates as they come.

In early August, UHC announced it would require prior authorization for physical and occupational therapy, speech-language pathology, and chiropractic services provided in multidisciplinary offices and outpatient hospital settings effective September 1, 2024. Services provided in the home would not be subject to prior authorization. ASHA Advocacy is pushing back against this policy as we believe prior authorization is an ineffective utilization management technique that delays access to care for patients and increases administrative burden for clinicians.

What Speech-Language Pathologists Need to Know

Multidisciplinary practices are defined as settings where physical therapy, occupational therapy, speech therapy, and/or chiropractic care are all provided within a single facility or office.

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 policy applies to UnitedHealthcare® Medicare Advantage plans nationally, including:

Medicare Individual (including Chronic Special Needs Plans)
Medicare Group Retiree
UHCWest Medicare plans in Nevada, Oregon, Washington, and Texas
UHCWest Medicare plans in Colorado (which will begin on January 1, 2025).

The policy does not apply to the following 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.

UHC notes that current prior authorization requirements in Arkansas, Georgia, South Carolina, and New Jersey for outpatient therapies continue as previously deployed and will now include Medicare-covered chiropractic services.

The policy requires providers to submit a prior authorization request after completing the initial evaluation. UHC outlined data about the program’s implementation that showed it had processed more than 200,000 prior authorization requests since September 1, and that approximately 86% of these requests were either fully or partially approved. It stated that the average processing time is four business days. However, members continue to report waiting eight to 10 business days for approval. While UHC did not state how many visits were typically approved, ASHA members report they are approved for eight visits per request.

How to Submit a Prior Authorization Request

Health care providers must submit the initial evaluation results and the plan of care (including the number of requested visits) by completing an outpatient assessment form. If additional visits are needed after the initial treatment plan is completed, health care providers will need to submit an additional prior authorization request. Full details on how to log in to the UHC website and submit a request (including a link to the prior authorization request form) are found in the announcement.

UHC notes it will review prior authorization requests for medical necessity using the criteria outlined in Chapter 15 of the Medicare Benefit Policy Manual [PDF], applicable local coverage determinations, and InterQual criteria. 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 UHC’s medical necessity determination.

What ASHA Is Doing

ASHA is meeting with UHC officials to understand the rationale for the policy and to ask for reconsideration. At a minimum, we are asking UHC to delay implementation and narrow the scope of services subject to prior authorization.

Both federal agencies such as the Government Accountability Office and nonpartisan organizations such as the Kaiser Family Foundation have found that prior authorization is an ineffective utilization management technique that inappropriately and unnecessarily delays access to care for patients and increases administrative burden for clinicians. As a result, ASHA has banded together with other therapy organizations to send a joint letter to UHC encouraging it to retract the policy immediately.