ModifiedColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization for outpatient PT, OT, and ST services

Governs prior authorization requirements for outpatient physical, occupational, and speech therapy services and explains submission, documentation, and review processes for providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization for outpatient PT, OT, and ST services

Policy CodePolicy N/A

Change TypeRevised authorization workflow

Effective DateNov 1, 2022

Next Review DateN/A

Key ActionSubmit an initial prior authorization request after the evaluation to receive up to 12 visits per discipline per episode without clinical review.

SourceLink

POLICY UPDATE CHANGES

Effective Nov. 1, 2022, prior authorization is required after the initial evaluation and up to 12 visits per discipline, per episode (48 timed units) will be approved without clinical review.

12initial approved visits

48equivalent timed units

14 dayssubmit window before service

0-3 daystypical review time

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Authorization and documentation criteria

Covered when ALL of the following are met

Initial authorization: An initial prior authorization request must be submitted after the initial evaluation; the request will be approved for up to 12 visits per discipline per episode (48 timed units) without clinical review.12 visits / 48 units

Providers must still submit an initial request though no clinical information is required for initial approval.

Continued services after initial authorization: Once the initial 12 visits (or 48 timed units) are exhausted, submit a new prior authorization request with required documentation (signed physician order, current evaluation/reevaluation and plan of care, progress or daily treatment notes).authorization after 12 visits

Medical necessity review will be performed for requests beyond the initial 12 visits.

Documentation timing and duration: For members younger than 21, submit a signed and dated physician order less than 30 days old, a current evaluation/reevaluation and plan of care (plan duration up to 90 days). For members 21 and older, submit a signed and dated physician order less than 30 days old, a current evaluation/reevaluation and plan of care (plan duration up to 60 days) and an exam note describing the need for evaluation.order <30 days; plan duration: <21 = 90 days, >=21 = 60 days

For speech therapy initial evaluations in members younger than 6, include hearing screening per EPSDT.

Initial and ongoing outpatient therapy coverage

Covered when meeting plan and medical necessity rules described:

Initial authorization: Initial prior authorization grants up to 12 visits per episode (48 timed units) per discipline per calendar year.12 visits / 48 units

Initial approval is granted without clinical medical necessity review.

Additional services: After the initial 12 visits (48 units) are used, a new prior authorization with complete documentation is required; a formal medical necessity review will be performed.medical necessity review

Submit signed physician order, current evaluation/reevaluation, plan of care, and progress or daily treatment notes as applicable.

Treatment span: Maximum treatment span duration for ongoing services is up to 6 months; reevaluations more often than once every 6 months should only be completed when there is a significant change in the member's functional status.

Services provided without an approved prior authorization will be denied. For dates of service on or after Nov. 1, 2022, providers must submit an initial prior authorization request for ongoing PT, OT, or ST services after the initial evaluation; claims submitted without an approved prior authorization on file before the date of service will be denied and members cannot be balance billed for those services.

Prior authorization requirements do not apply to members receiving care in skilled or rehabilitation (inpatient) facilities, because therapy in those settings is used to qualify the skilled level of care and is part of the inpatient authorization. Prior authorization does apply to all outpatient settings — including home health, long‑term care residence, office, and hospital outpatient services — and therefore includes residents of custodial or long‑term care facilities when the therapy is delivered as an outpatient service.

Codes, Units, and Quantity Limits

Ongoing treatment codes requiring prior authorizationmixed

See payer page

Complete list of ongoing treatment codes requiring prior authorization is provided on the UnitedHealthcare Community Plan of Nebraska prior authorization page.

inv-06: Initial approved visits — 12 visits per discipline per episode (48 timed units)

Initial approved visits12 visits per discipline per episode (48 timed units)

ScopeApplies to PT, OT and ST for UnitedHealthcare Community Plan members in Nebraska

Approval without clinical reviewThese initial 12 visits per episode are approved without clinical medical necessity review, but a prior authorization request must still be submitted

inv-07: Timed units per visit — one visit equals up to 4 timed units per day per discipline

Timed units per visitOne visit equals up to 4 timed units of services per day per discipline

Multiple modalitiesMultiple modalities performed by one discipline on the same day count as one visit

Counting ruleTimed units are applied per discipline per day when calculating visit totals

inv-08: Initial authorization visits/units — 12 visits per episode or 48 timed units annually prior to medical necessity review

Initial authorization allowance12 visits per episode or 48 timed units annually prior to medical necessity review

When additional auth is requiredOnce the initial 12 visits (48 timed units) are exhausted, a new prior authorization request with complete documentation is required

Medical necessity reviewFormal medical necessity review is performed for requests beyond the initial 12 visits per episode (48 units)

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for ongoing therapy treatment codes (PT, OT, ST). Providers must submit an initial prior authorization request for ongoing services after the initial evaluation to receive the automatic 12-visit episode approval; however, once the initial 12 visits (or 48 timed units) are exhausted, submit a new prior authorization with required documentation for extension and medical necessity review.

Initial authorizations: up to 12 visits per discipline per episode (48 timed units) approved without clinical review.
After the 12th visit (48 timed units) is exhausted, a new prior authorization request is required and will be reviewed for medical necessity.

Denial Risk

Denial if No Prior Authorization / Denial Notification

If no approved prior authorization is on file before the date of service, claims will be denied and members cannot be balance billed. Denials will be communicated to the treating therapist by phone and by letter to both the therapist and the member.

Claims for services without prior authorization will be denied.
Members cannot be balance billed for denied services.
Denial notification: phone to treating therapist and written notification to therapist and member.

Documentation Required

Required Documentation by Age & For Extensions

Documentation requirements differ by member age. Submit the listed items with extension requests or when clinical review is required beyond the initial 12 visits per episode. Keep required documentation in the patient record for audit purposes.

Members younger than 21: signed and dated physician order (≤30 days old) specifying discipline(s); current evaluation/reevaluation report and plan of care (plan may cover up to 90 days; beyond 90 days requires a new authorization and plan of care); current well-child visit or exam note; for ST initial evals <6 years, include hearing screening per EPSDT schedule.
Members 21 and older: signed and dated physician order (≤30 days old) specifying discipline(s); current evaluation/reevaluation report and plan of care (plan may cover up to 60 days; beyond 60 days requires a new authorization and plan of care); exam note describing need for evaluation(s).
Signed physician or APRN order is not required at time of requesting the initial 12 visits per episode but must be in the patient file for audit; for extension/medical-necessity review, include the signed order and complete documentation.

Documentation Required

Documentation Required for Extension Requests

When requesting services beyond the initial 12 visits per episode (48 timed units), submit a new prior authorization request with complete supporting documentation to allow medical necessity review and authorization of additional visits or new episodes of care.

Extension requests must include current evaluation/reevaluation, plan of care, progress report or most recent daily treatment notes, and the signed physician/APRN order as part of the patient file.
New episodes or changes in condition require a separate prior authorization request that complies with the therapy policy documentation requirements.

Prior Authorization

Episode and Concurrent-Discipline Authorization Rules

Authorizations are managed per discipline and per episode. The initial authorization grants 12 visits per discipline per episode; concurrent cases in the same discipline with a second provider require a separate prior authorization for medical necessity review.

Each discipline (PT, OT, ST) receives 12 visits per episode (48 timed units) per calendar year as the initial approval.
If a member has two concurrent cases in the same discipline (different injuries or different providers), the second provider must submit a prior authorization request for medical necessity review.
When UnitedHealthcare Community Plan is secondary (Medicaid secondary), prior authorization is not required; if UHC Community Plan becomes primary, authorization is required prior to services.

Policy Background and Scope

This policy establishes an administrative prior authorization and medical necessity review process for outpatient physical, occupational, and speech therapy services effective Nov. 1, 2022. Providers must submit an initial prior authorization request after the initial evaluation; the policy issues an automatic approval for up to 12 visits per discipline per episode (equivalent to 48 timed units) without clinical review. Once those initial visits or units are exhausted, providers must submit a new prior authorization request with complete documentation (signed physician/APRN order, current evaluation or reevaluation and plan of care, and progress or daily treatment notes) so that a formal medical necessity review can be performed. Claims for services rendered without an approved prior authorization on file before the date of service will be denied and members may not be balance billed; denials are communicated to the treating therapist and member per the plan's notification process.

Key Definitions

inv-21: Episode — define episode as used in this policy

DefinitionAn episode refers to a course of care for a specific discipline (PT, OT or ST) for a condition; each discipline receives its own episode authorization

Per-episode allocationBased on the initial prior authorization request, each discipline is allotted 12 visits per episode (48 units for timed services)

New episodeAuthorization for any new episodes of care or condition requires submission of a new prior authorization request

inv-22: One visit — one visit equals up to 4 timed units per day per discipline

One visit equalsUp to 4 timed units of services per day per discipline

Same-day servicesMultiple modalities performed by one discipline on the same day count as a single visit

ApplicationUse per-discipline, per-day visit counting when calculating the 12-visit (48-unit) episode allowance

inv-23: Reevaluation frequency — recommended interval (not more often than every 6 months unless significant change)

Recommended intervalReevaluations should not be performed more often than once every 6 months

ExceptionReevaluation sooner than 6 months is permitted only when the member experiences a significant change in functional level or status

PurposeMaximum treatment span for ongoing services is up to 6 months; reevaluation timing supports this treatment span

OpenPayer

Prior authorization for outpatient PT, OT, and ST services

Coverage and Medical Necessity Criteria

Codes, Units, and Quantity Limits

What Providers Must Do

Policy Background and Scope

Key Definitions