CurrentUnitedHealthcarePolicy PCA-1-24-02372-Clinical-FAQ_08202024

Prior authorization requirements for PT, OT and ST services — UnitedHealthcare Community Plan of Nebraska (FAQ)

Governs prior authorization requirements for outpatient occupational, physical, and speech therapy services for UnitedHealthcare Community Plan members in Nebraska; affects treating providers who deliver PT, OT, or ST and submit authorization requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for PT, OT and ST services — UnitedHealthcare Community Plan of Nebraska (FAQ)

Policy CodePolicy PCA-1-24-02372-Clinical-FAQ_08202024

Change TypeNo material change

Effective DateNov 1, 2022

Next Review Date

Key ActionSubmit an initial prior authorization request after the evaluation to obtain the initial authorization (12 visits per discipline/48 timed units).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12initial approved visits per discipline

48initial approved timed units

14 dayssubmit request up to

14 daystypical processing time

5 business days

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Coverage and Medical Necessity Criteria

inv-01: Initial and Additional Visit Authorization

Covered when the following administrative steps are met

Initial authorization: Submit an initial prior authorization request after the evaluation; the initial authorization will approve up to 12 visits per discipline per episode (48 timed units) without clinical medical necessity review.12 visits / 48 timed units

Applies to members new to therapy and those currently receiving therapy

Authorization for additional services: When the initial 12 visits per episode (48 timed units) are exhausted, submit a new prior authorization request with complete documentation for any additional services or new episodes of care; a formal medical necessity review will be performed for requests beyond the initial allotment.N/A

New request must comply with the prior authorization and documentation requirements in the referenced guidelines

inv-02: Coverage and continuation criteria

Covered when the following administrative and clinical conditions are met:

Episode allotment: Initial coverage: up to 12 visits per episode (48 timed units) per discipline per calendar year.12 visits / 48 units

After exhaustion, prior authorization with documentation required for medical necessity review.

Treatment span: Maximum approved treatment span for ongoing services is up to 6 months.<= 6 months

Reevaluations more often than every 6 months should only occur with significant change in functional status.

Age-based limits (Heritage Health NE): Members ages 21 and older have a combined total limit of 60 therapy sessions per calendar year across OT, PT, and ST. Members 20 and younger are covered for evaluations, restorative therapy with an expectation of significant improvement, or services recommended in a DHHS‑approved IPP waiver program.

If an approved prior authorization is not on file before the date of service, the claim will be denied and the member cannot be billed. Do not provide services that require prior authorization without an authorization on file. Denials will be communicated by phone and by letter to the treating therapist and the member.

Prior authorization does not apply to members in skilled or rehabilitation facilities (inpatient services). These settings are considered inpatient and therapy provided as part of skilled care is the qualifier for approval of the skilled level of care. Prior authorization does apply to outpatient settings, including home health, long‑term care residence, office, and hospital outpatient services.

For members ages 20 and younger, coverage is limited to: evaluations; restorative therapy with a medically appropriate expectation of significant improvement within a reasonable period; or services recommended in a DHHS‑approved Individual Program Plan (IPP) when the member is receiving services through an approved DHHS waiver program. Other therapies for this age group may not meet medical necessity under the Heritage Health Nebraska program.

Codes, Units, and Visit Limits

Ongoing treatment codes requiring prior authmixed

affected codes

Ongoing treatment codes require prior authorization; see full list on prior authorization page.

Initial visits per discipline

Initial visits per discipline12 visits per discipline per episode (equates to 48 timed units)

Timing of authorizationSubmit initial prior authorization request after the evaluation; no clinical information required at time of initial request

Action after exhaustionWhen the 12th visit (48 timed units) is exhausted, submit a new prior authorization with required documentation for medical necessity review

Units per visit

Units per visitOne visit = up to 4 units of timed services per day per discipline

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

Provider Steps, Timing, and Documentation Requirements

Prior Authorization

Visit-limited initial authorization

For dates of service on or after Nov. 1, 2022, submit an initial prior authorization request after the initial evaluation for ongoing PT, OT, or ST services. The initial authorization grants up to 12 visits per discipline per episode (or 48 timed units). Once that allotment is exhausted you must submit a new prior authorization request with supporting documentation for additional services; we will conduct a medical-necessity review for requests beyond the initial allotment.

Initial authorization = up to 12 visits per discipline per episode (or 48 timed units).
After the 12th visit (48 timed units) is used, submit a new prior authorization request for continuation.
New requests must include required documentation (evaluation/reevaluation, plan of care, physician order where applicable) for medical necessity review.

Prior Authorization

Episode-based visit gating

Providers receive a fixed episode allotment based on the initial prior authorization request: 12 visits per discipline per episode (48 timed units). Additional services after that episode allotment require a new prior authorization and full clinical documentation to support medical necessity. This episode-based gating applies per discipline and per calendar year.

Policy Background and Scope

This document explains administrative prior authorization and documentation processes for outpatient physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services for UnitedHealthcare Community Plan members in Nebraska. It describes the workflow for initial approval—where an initial authorization of 12 visits per discipline (up to 48 timed units) is granted after the evaluation without clinical medical necessity review—and the requirement to submit a new prior authorization with complete documentation for any services beyond that initial allotment.

Key Definitions

Episode

DefinitionEpisode

Episode allotmentInitial authorization grants up to 12 visits per episode per discipline

PurposeEpisode defines the initial fixed allotment after an evaluation for which prior authorization is granted

One visit

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

Counting multiple modalitiesMultiple modalities by one discipline on the same day count as one visit

Relation to episode allotment