DraftUnitedHealthcarePolicy CS164NJ.G

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Jersey Only)

Policy governing medical necessity, documentation, evaluation, plan of care, continuation, re-evaluation, and discharge criteria for outpatient occupational, physical, and speech therapy services for members in New Jersey.

Policy Summary

PayerUnitedHealthcare

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Jersey Only)

Policy CodePolicy CS164NJ.G

Change TypeClarification and additions to coverage rationale and speech/language testing

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain and submit a completed evaluation with referral/order, documented plan of care, and objective measures to support authorization requests.

SourceLink

POLICY UPDATE CHANGES

Added Clinical Evidence section and updated Description of Services and References.

Coverage language added to indicate services must not duplicate services provided concurrently by another therapy type and must have different goals, plans, and modalities.

Speech and language considerations for bilingual/multilingual individuals and testing requirements were added.

Removed previous notation that a list of CPT/HCPCS codes are not on the NJ Medicaid Fee Schedule.

30min session length (physician's office)

6 monthsmax authorization period

6 monthsre-eval frequency

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

90 daysPOC/progress summary recency

Coverage Criteria

Initial Therapy Evaluation / Authorization Criteria

Covered when ALL of the following are met

Referral/Order: A provider (MD, DO, PA, or NP) or appropriate specialist referral for the speech, physical, or occupational therapy evaluation must be on file prior to completion of the evaluation unless exempted by state regulation.

Evaluation Content: The therapy evaluation report includes medical history; comparison of prior level of function to current level; description of the individual's functional impairment and its impact on health, safety, and/or independence; a clear diagnosis with ICD-10 code; a reasonable prognosis including potential for meaningful progress; and baseline objective measurements (standardized assessment scores, age equivalents, percentage of functional delay, criterion-referenced scores) or, if assessments are not feasible, an objective task analysis and supporting checklists/caregiver reports/clinical observation.

Plan of Care: Initial authorization must include a plan of care (POC) based on the evaluation that documents the functional or physical impairment, measurable short- and long-term functional goals (specific, measurable, attainable, time-based), and the proposed treatment frequency, duration, and anticipated session length.

Continuation / Re-evaluation Criteria

Covered when ALL of the following are met

Progress Documentation: Request must include weeks of therapy previously authorized or visits attended and the individual's current status compared to the evaluation baseline using objective measures demonstrating continued impairment.

Need for Skilled Services: Documentation must demonstrate the provision of and ongoing need for skilled therapeutic services and include an updated POC specifying frequency and duration.

Re-evaluation Requirements: Re-evaluations must be completed at least once every six months (or more frequently per state rules) and include current standardized assessment scores or equivalent objective data, documentation of progress toward each treatment goal using consistent comparable methods, an updated POC with measurable functional time-based goals, a brief prognosis with discharge criteria, and the updated POC/progress summary must not be older than 90 days.

Coverage Rationale and Language Considerations

Covered when services meet medical necessity for habilitation or rehabilitation and are not duplicative of concurrent therapy services.

General medical necessity: Services must be intended to improve, adapt, or restore function (rehabilitative) or to help keep, learn, or improve daily living skills (habilitative). Maintenance therapy is supportive; it is appropriate only to prevent deterioration when further clinical improvement cannot reasonably be expected.

From Description of Services

Non-duplication requirement: Therapy services must not duplicate services of another therapy type provided concurrently; concurrently provided therapies must have different treatment goals, plans, and therapeutic modalities.

Added to Coverage Rationale

Speech and language considerations for bilingual/multilingual individuals: Bilingual and multilingual speakers should not be misclassified as developmentally delayed; equivalent proficiency in both languages should not be expected. Individuals with limited English proficiency must receive culturally and linguistically adapted norm-referenced standardized testing in all languages the child is exposed to; service delivery should be in the language of highest receptive proficiency. For individuals with dyslexia, test results substantiating receptive or expressive language delay must be included and goals must address the corresponding language deficits.

This Medical Policy does not apply to cognitive therapy. Outpatient cognitive therapy is addressed separately in the Medical Policy titled "Cognitive Rehabilitation (for New Jersey Only)."

Therapy services that are provided concurrently by another therapy type (for example, speech, physical, or occupational therapy) must not duplicate those services. Concurrent therapies must have different treatment goals, plans, and therapeutic modalities to be considered separate, reimbursable services.

Services are not medically necessary when they no longer require the skill of a therapist or when documentation fails to demonstrate objective, measurable progress toward treatment goals. Treatment notes must document date, specific treatments matching billed CPT codes, session length, the individual's response, ongoing skilled reassessment, and progress in objective terms; discharge is appropriate when goals are met or therapist skill is no longer required.

When ongoing care is supportive rather than corrective and further clinical improvement cannot reasonably be expected, the services are considered maintenance therapy. Maintenance therapy focuses on preventing deterioration or preserving function; whether maintenance services are covered depends on the member's benefit terms and whether continued skilled intervention is medically necessary.

Applicable Codes and Coding Notes

Applicable Speech/Language CodesCPT

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals.
92521	Evaluation of speech fluency (e.g., stuttering, cluttering).
92522	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria).
92523	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language).
92524	Behavioral and qualitative analysis of voice and resonance.
92526	Treatment of swallowing dysfunction and/or oral function for feeding.
92609	Therapeutic services for the use of speech-generating device, including programming and modification.
92610	Evaluation of oral and pharyngeal swallowing function.
96105	Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour.

Applicable PT/OT/Modality and Evaluation CodesCPT

97012	Application of a modality to 1 or more areas; traction, mechanical.
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended).
97016	Application of a modality to 1 or more areas; vasopneumatic devices.
97018	Application of a modality to 1 or more areas; paraffin bath.
97022	Application of a modality to 1 or more areas; whirlpool.
97024	Application of a modality to 1 or more areas; diathermy (e.g., microwave).
97026	Application of a modality to 1 or more areas; infrared.
97028	Application of a modality to 1 or more areas; ultraviolet.
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.
97033	Application of a modality to 1 or more areas; iontophoresis, each 15 minutes.

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Applicable CPT/HCPCS Codesmixed

97164	Re-evaluation of physical therapy established plan of care
97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
97168	Re-evaluation of occupational therapy established plan of care
97530	Therapeutic activities, direct (one-on-one), each 15 minutes
97535	Self-care/home management training, direct one-on-one, each 15 minutes
97542	Wheelchair management, each 15 minutes
97750	Physical performance test or measurement with written report, each 15 minutes
97755	Assistive technology assessment with written report, each 15 minutes

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State fee schedule notesHCPCS

*G0281	Not on NJ Medicaid Fee Schedule note
G0283	May not be covered by NJ Medicaid if not on fee schedule

Initial therapy session length (physician's office)

Minimum session length (physician's office)>= 30 minutes (treatment shall be individual and consist of a minimum of 30 minutes per NJAC § 10:54-5.35)

Applicable settingPhysician's office (NJ-specific regulatory requirement)

Related authorization periodUnitedHealthcare may authorize therapies for up to six months upon clinical review

Re-evaluation frequency

Minimum re-evaluation frequencyAt least once every 6 months

State variation

Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization Requirement

Prior Authorization Required — UnitedHealthcare may authorize therapy services based on InterQual criteria and a documented plan of care (POC) for up to six months when medically appropriate. Authorizations are determined using InterQual in conjunction with documentation provided. Services must not duplicate concurrent therapy provided by another therapy type and must have distinct goals, plans, and therapeutic modalities.

Authorizations may be issued for up to six months based on clinical review and InterQual.
Services that duplicate concurrent therapy (e.g., identical goals/modalities across speech, physical, and occupational therapy) may be denied.

Prior Authorization

Verify Benefit-Specific Prior Authorization

Verify benefit-specific prior authorization and coverage rules before initiating services. Federal, state, or contractual plan terms may override this policy; in the event of a conflict, those plan-specific requirements govern. Check member benefit documents and any state-specific mandates (for example, NJ requirements noted herein) to confirm whether a referral or prior authorization is required.

Definitions

Initial Therapy Evaluation — definition and required documentation elements

DefinitionAn initial therapy evaluation requires a referral/order on file (MD, DO, PA, NP, or appropriate specialist) prior to completion unless state exempts; the evaluation determines need for therapy and establishes baseline function.

Required documentation - history and diagnosisStatement of medical history and a clear diagnosis with appropriate ICD-10 code.

Required documentation - functional baselineComparison of prior vs current level of function and baseline objective measurements or standardized assessment scores (or task analysis when assessments are not feasible).

Required documentation - prognosis and goalsReasonable prognosis including potential for meaningful progress and an initial plan of care with measurable short- and long-term goals, frequency/duration, and session length.

Re-evaluation — periodic reassessment and required contents

Background

Rehabilitative services are intended to improve, adapt, or restore functions lost or impaired by illness, injury, or congenital abnormality and typically involve achievable goals with therapist assistance. Habilitation services help an individual keep, learn, or improve daily living skills (for example, a child not walking or talking at the expected age). Maintenance therapy seeks to prevent deterioration when further clinical improvement cannot reasonably be expected and is supportive rather than corrective. For rehabilitative physical and speech-language therapy performed in a physician's office, treatment must be individual and consist of a minimum of 30 minutes. UnitedHealthcare may authorize therapies based on clinical review and documented plan of care for up to 6 months.

Policy Summary

PayerUnitedHealthcare

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Jersey Only)

Policy CodePolicy CS164NJ.G

Change TypeClarification and additions to coverage rationale and speech/language testing

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain and submit a completed evaluation with referral/order, documented plan of care, and objective measures to support authorization requests.

SourceLink

On This Page

From Speech and Language Considerations

May be completed more frequently based on state regulatory requirements

Trigger for earlier re-evaluationSignificant change in functional level/condition warrants sooner re-evaluation

Typical face-to-face time for evaluations

97164 (PT re-evaluation)Typically ~20 minutes face-to-face

97165 (OT evaluation, low complexity)Typically ~30 minutes face-to-face

97166 (OT evaluation, moderate complexity)Typically ~45 minutes face-to-face

97167 (OT evaluation, high complexity)Typically ~60 minutes face-to-face

97168 (OT re-evaluation)Typically ~30 minutes face-to-face

Confirm if a referring order from PCP or appropriate specialist (MD, DO, PA, NP) is required and on file prior to evaluation unless exempted by state rule.

Confirm whether specific CPT/HCPCS codes are subject to plan exclusions or state fee-schedule limitations.

Documentation Required

Required Documentation for Evaluation, POC, and Treatment Notes

Required documentation must accompany initial evaluations, plans of care, and treatment notes to support medical necessity and authorization requests. Documentation outlined below is used in addition to InterQual to assess coverage but does not guarantee payment.

Initial therapy evaluation must include: medical history; comparison of prior vs current function; description of functional impairment and its impact on health/safety/independence; clear diagnosis with ICD-10 code; reasonable prognosis; baseline objective measurements using current standardized assessments (or documented alternatives when standardized tests are not feasible).
Plan of Care must include: diagnosed functional/physical impairment; measurable short- and long-term functional goals that are specific, attainable, time-based, and related to the impairment; treatment frequency, duration, and anticipated length of sessions.
Treatment session notes must include date of treatment; specific treatments provided that match billed CPT code(s); accurate session length; patient response; skilled ongoing reassessment; objective documentation of progress toward goals; any POC changes; caregiver involvement/feedback; and treating provider signature and date.

Documentation Required

Evaluation/Re-evaluation Documentation

Evaluation and re-evaluation documentation must meet CPT-defined components and reflect the complexity of the evaluation performed. Use standardized tests and measures as appropriate and document findings, severity of deficits, clinical decision making, and revised POC when applicable.

Follow CPT definitions for evaluation/re-evaluation codes (e.g., PT/OT evals 97161–97168, re-evals 97164/97168) and document the exam, history review, standardized tests/measures, identified deficits, clinical decision making, and time spent face-to-face.
For occupational therapy evaluations (97165–97167) document the occupational profile, number/severity of performance deficits, and complexity of clinical decision making.
Perform and document formal re-evaluation whenever there is a documented change in functional status or a significant change to the plan of care; include revised goals and POC.
If standardized assessments cannot be completed due to medical condition, include in-depth task analysis, caregiver reports/interviews, and clinical observation as objective alternatives.

Denial Risk

Triggers for Denial

Triggers for Denial — Claims or authorization requests may be denied when required documentation or administrative requirements are missing, or when clinical documentation does not support billed services.

Missing or absent referral/order (when required by plan or state) prior to evaluation.
Insufficient or incomplete evaluation or plan of care (e.g., lacks history, baseline measurements, clear diagnosis, measurable goals, frequency/duration).
Treatment notes that do not align with billed CPT code(s) (e.g., modalities documented do not match code descriptors or billed time not supported by note).
Documentation that shows services are maintenance rather than restorative without clinical justification for skilled therapy.

Denial Risk

Duplication Risk

Duplication Risk — Services that duplicate concurrent therapy may be denied. Ensure that each therapy discipline provides distinct treatment goals, plans, and therapeutic modalities; chart notes should clearly differentiate the unique medical necessity and skilled interventions provided by each discipline.

Do not bill for multiple therapy services that provide the same interventions or goals during the same time period.
Document how each discipline's interventions differ in goals, modalities, and measurable outcomes to avoid denials for duplication.

DefinitionA re-evaluation is a periodic reassessment performed at least once every six months (or more often per state rules) to document ongoing need for skilled therapy and to update the plan of care.

Required contents - objective statusDate of last evaluation; number of visits authorized/attended; compliance to home program; description of current deficits with severity using objective data and standardized assessment scores.

Required contents - progress and POCObjective demonstration of progress toward each treatment goal, updated POC with measurable, time-based goals, revised treatment frequency/duration, brief prognosis, and clearly established discharge criteria (updated POC/progress summary must not be older than 90 days).

Rehabilitative services — definition

DefinitionRehabilitative services are intended to improve, adapt, or restore functions impaired or lost due to illness, injury, loss of a body part, or congenital abnormality; services involve achievable goals with therapist assistance and may include occupational, physical, or speech therapy.

Typical purposeRestore or maximize functional abilities and independence through targeted, therapist-directed interventions.

Service examplesOccupational, physical, and speech therapy interventions directed at functional improvement, adaptation, or restoration.

Habilitation services — definition

DefinitionHabilitation services help a person keep, learn, or improve skills and functioning for daily living (e.g., therapy for a child who is not walking or talking at the expected age).

Typical purposeDevelop new skills or functions that were not previously established, often for developmental or congenital conditions.

Service examplesPhysical and occupational therapy, speech-language pathology, and other services to improve daily living skills in individuals with disabilities.

Maintenance therapy — definition and intent

DefinitionMaintenance therapy includes services that seek to prevent deterioration or maintain current function when further clinical improvement cannot reasonably be expected; treatment is supportive rather than corrective.

IntentTo preserve function, promote health, and enhance quality of life rather than to produce additional measurable improvement.

Coverage considerationWhen therapy is maintenance in nature and further improvement is not expected, services may be considered non‑covered depending on benefit terms; documentation must support medical necessity for continued services.