UnitedHealthcare has recently expanded its prior authorization requirements for therapy and chiropractic services under its Medicare Advantage plans. These changes aim to streamline provider access to coverage information but also introduce new administrative processes that may affect patient care and provider workflows. This update outlines the key aspects of the new policies, their implications for clinicians, and ongoing advocacy efforts to ensure efficient and patient-centered care delivery.
Introduction
Effective March 2025, UnitedHealthcare has rolled out system upgrades designed to provide therapists and chiropractors with real-time coverage updates during the patient treatment planning process. This initiative is intended to facilitate immediate treatment authorization after initial evaluations by displaying approval status directly within the provider’s submission portal. Providers will now see whether services for up to six visits over an eight-week period are approved immediately, simplifying the initial authorization process for many cases. However, for plans requesting more extensive treatment beyond this scope, additional documentation and medical necessity reviews remain mandatory, potentially lengthening approval times and increasing administrative burdens.
While these technological enhancements could help clinicians better coordinate care, concerns persist regarding their impact on clinical judgment and overall access. The requirement for detailed prior authorization for plans exceeding six visits may lead to delays, especially if post-payment audits identify coverage issues. For more detailed information, providers are encouraged to review the updated FAQ [PDF].
Recent Policy Changes and Stakeholder Reactions
In a further update from January 2025, UHC announced modifications to its Medicare Advantage prior authorization procedures that reflect feedback from healthcare stakeholders. These changes, effective January 13, 2025, do not alter the fundamental requirement to submit prior authorization requests through UHC’s portal for all therapy and chiropractic services. However, for new patients or those with significant gaps in care, approval for up to six visits within the first eight weeks will be granted automatically, without a clinical review. Any additional visits beyond this threshold will require a formal review to determine medical necessity.
This approach aims to expedite access to some services but does not fully address the administrative challenges clinicians face or the potential for delays if post-approval audits find services do not meet criteria. The policy also raises questions about compatibility with federal Medicare regulations, which aim to prevent unnecessary utilization management practices. Advocacy groups, including ASHA, continue to engage with UHC and CMS to seek policy adjustments that better balance oversight with timely patient care.
In September 2024, UHC announced that prior authorization would be required for outpatient therapy and chiropractic services provided in certain multispecialty and outpatient hospital settings, excluding services in the home. This policy affects numerous plans across states including Nevada, Oregon, Washington, Texas, and Colorado, with some plans set to implement changes as early as January 2025. Providers are advised to familiarize themselves with the specific codes and documentation procedures necessary to comply with these new requirements.
Practical Guidance for Submission of Prior Authorization Requests
Healthcare providers are responsible for submitting comprehensive plans of care, including details about the number of visits requested, via the designated outpatient assessment form. After submission, UHC reviews requests for medical necessity based on established criteria, including the Medicare Benefit Policy Manual and local coverage determinations, with licensed professionals such as speech-language pathologists and physical therapists conducting evaluations.
Providers should be aware that requests for more than six visits within the initial eight-week period may undergo review, potentially causing delays. To assist clinicians, UHC provides step-by-step instructions for online submission and outlines the documentation needed for efficient processing. Timely and accurate submissions are critical, as delays can hinder patient access to essential therapies.
Ongoing Advocacy and Future Outlook
ASHA remains actively engaged with UHC and federal agencies to advocate for streamlined processes that prioritize patient-centered care. Our ongoing efforts include discussions with UHC officials and joint advocacy letters with other therapy organizations, emphasizing that current prior authorization practices can unnecessarily delay access and increase administrative workload. Studies from organizations like the Kaiser Family Foundation highlight the inefficiencies of prior authorization as a utilization management tool, reinforcing the importance of policy reform.
ASHA continues to monitor developments and will inform members of significant updates. Clinicians are encouraged to communicate directly with UHC for clarifications and to report any concerns related to the authorization process.
Additional Resources and References
Healthcare providers interested in understanding the broader context of healthcare technological integration can explore insights on how innovations are shaping clinical workflows by reviewing resources on healthcare AI applications. Ensuring data privacy in these evolving environments is equally important; guidance on protecting patient information remains essential for compliance and trust.
Looking ahead, the future of AI in healthcare continues to be a topic of significant interest, with emerging trends shaping policy and practice. For in-depth analysis, visit future trends in AI. Lastly, the use of big data analytics provides powerful tools for unlocking clinical insights and improving patient outcomes; learn more about how this technology is transforming healthcare by exploring big data analytics.
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For further questions or to share feedback, contact ASHA’s health policy team at reimbursment@asha.org.