CurrentUnitedHealthcarePolicy CS161FL.L

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) - Site of Service (for Florida Only)

Defines site-of-service coverage guidance for outpatient occupational, physical, and speech therapy for UnitedHealthcare Community Medicaid Plans in Florida, emphasizing use of cost-effective non-hospital (free-standing) settings when medically appropriate and listing exceptions where outpatient hospital care may be appropriate.

Policy Summary

PayerUnitedHealthcare

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) - Site of Service (for Florida Only)

Policy CodePolicy CS161FL.L

Change TypeRevised (references updated)

Effective DateJul 1, 2025

Next Review Date

Key ActionProviders must ensure services meet the policy's Medical Necessity definition and consider state/federal/contract requirements and free-standing facility capability when selecting site of service.

POLICY UPDATE CHANGES

Updated References section to reflect the most current information and archived previous policy version CS161FL.K.

1State-specific policy (Florida only)

MultipleReferenced CPT/HCPCS codes listed

4Examples of conditions warranting outpatient hospital site

Coverage Summary

Policy Number CS161FL.L. Effective Date July 1, 2025; Last review July 1, 2025. This policy defines site-of-service coverage guidance for outpatient occupational, physical, and speech therapy for UnitedHealthcare Community Medicaid Plans in Florida, with the stated purpose of covering more cost-effective sites of care for certain outpatient therapy services when medically appropriate and to improve cost efficiencies for the overall health care system.

The policy emphasizes that outpatient therapy procedures are generally appropriate to be provided in free-standing, non-hospital facilities when medically necessary and cost effective, while identifying circumstances and exceptions where an outpatient hospital site of care may be appropriate. Summary of Changes dated 07/01/2025 notes updated references and archiving of the prior policy version CS161FL.K.

Key Policy Attributes

Policy numberCS161FL.L

SubjectHabilitation and Rehabilitation Therapy Site of Service (Florida)

ScopeSite-of-service guidance for outpatient occupational, physical, and speech therapy for UnitedHealthcare Community Medicaid Plans in Florida; emphasizes cost-effective free-standing non-hospital settings when medically appropriate and lists outpatient hospital exceptions.

Effective dateJuly 1, 2025

Last reviewJuly 1, 2025

State-specific policyApplies to Florida only

Definitions & Policy Context

The policy aims to promote cost-effective sites of care for outpatient speech, occupational, and physical therapy by favoring free-standing, non-hospital facilities when services can be safely and effectively provided there and are Medically Necessary, including consideration of cost effectiveness and the policy's Medical Necessity definition.

It specifically applies to UnitedHealthcare Community Medicaid Plans in the state of Florida and directs that determinations must take into account the State Medicaid contract, any federal or state requirements, geographic availability of in-network providers, and the free-standing clinic or facility capability to accommodate all necessary services when selecting the site of service.

Definitions

Operational Considerations

Referenced Codes

Referenced CPT/HCPCS Codes (for outpatient therapy procedures and evaluations) - informationalmixed

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
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
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 with interpretation and report, per hour

1–10 of 55

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Provider Actions & Requirements

Documentation Required

Medically Necessary Determination & Documentation

Providers must ensure that outpatient speech, occupational, and physical therapy services meet the policy's Medical Necessity definition (protect life, prevent significant illness or disability, individualized and consistent with diagnosis, not experimental, provided at an appropriate level, and cost-effective). When selecting the site of service, providers should take into account the state Medicaid contract, any federal or state requirements, geographic availability of in-network providers, and the free-standing clinic/facility capability to accommodate required services.

Prior Authorization

Prior Authorization Reference

Refer to the UnitedHealthcare Medical Policy titled 'Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only)' for the documentation requirements and criteria used to prior authorize therapy evaluations and visits. That Medical Policy is the source for prior authorization requirements for evaluation and therapy visits.

UnitedHealthcare Medical Policy: Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only) is the source for documentation and prior authorization criteria.