UnitedHealthcare Medicare Advantage Prior Authorization January 2025 Update
UnitedHeathcare (UHC) Medicare Advantage has updated the prior authorization process for outpatient physical, occupational, and speech therapy services. In this article, I will answer the following questions:
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is this for in AND out of network providers or JUST IN network?
Read the answer to the last question and click on the second resource to obtain your answer.
Hi Rick, UHC still requires prior authorization for MA if a clinic is OON. We’ve had multiple claims denied initially in Sept 24′. The exclusions list they published in Sept 24′ has always been inaccurate. We had spoken to multiple reps from UHC again this week and they had stated this latest “update” had removed the OON Exclusion for MA plans. Of course we still haven’t gotten one consistent answer every time we call.
Go to the last question and answer and click on the second resource and that is the latest information for UHC regarding exclusions. Also, read page 2 of the FAQ document and it states who it applies to.
If we use the first 6 allowed visits with UHC advantage plans before the 8 weeks can we ask for more before the 8 weeks?
Yes, but they would require clinical review.
Can I bill the 2-6 visit without the authorization code that we receive after submitting for AUTH? I could not find this information on the UHC site. Melinda
UHC recommends submitting claims after receiving the authorization response.
Is it accurate that if providing therapy in a SNF for a resident, under their part b UHC benefit, prior auth is not required?
Please read the answer to the last question in this article. In the answer, click on the second resource to see which settings prior authorization applies to.
I feel like the timing of when to do the auth is still a bit muddy. If they are allowing 6 visits within 8 weeks, do we still do the auth at the start of PT or do we wait until they are close to using their initial 6 visits or 8 weeks (whichever comes first)?
Read the answer to the second question as well as review the resources available in the last question.
Just confirming we submit auth right away and don’t wait till the 6 are used (without needing clinical review). As your example above for requesting 12 (the 1st six are approved without clinical review) when we get that auth back those are included in the total of at 12–so really have 6 others approved. Correct??
Submit right away.
Do you have any idea what UHC’s clinical review after the 6 visits will entail?
I do not.
Hello. UHC denied my December claims for UHC MC Advantage stating that I did not have the prior auth. I thought this started in January 2025? Please advise if anyone else had the same issue and did UHC correct? Thank you Deborah Austin 561-750-4311 Debaustin@bellsouth.net
You would have wanted to read this article from back in August 2024.
https://gawendaseminars.com/unitedhealthcare-to-require-prior-authorization/