Billing / Fees / Insurance

UHC/Optum Requires Preauthorization for Medicare-Covered Chiropractic Services

Samuel A. Collins | DIGITAL EXCLUSIVE

WHAT YOU NEED TO KNOW

As of Sept. 1, 2024, UHC/Optum is requiring prior authorization for Medicare-covered chiropractic services (when billed with the AT-modifier) delivered in office and outpatient hospital settings, excluding services in the home.
Prior authorization is not required for claims for the initial evaluation to be considered for reimbursement. However, prior authorization is required for the treatment plan, which specifies the number of visits.
This applies to UnitedHealthcare Medicare Advantage nationally, excluding Dual Complete Special Needs Plans (SNP).

Editor's Note: Article submitted by our "Ask the Billing Expert" columnist, Sam Collins.

Effective Sept. 1, 2024, UHC/Optum is requiring prior authorization for the following services delivered in office and outpatient hospital settings, excluding services in the home: Medicare-covered chiropractic services (when billed with the AT-modifier), as well as physical therapy (PT), occupational therapy (OT), and speech therapy (ST).

The affected procedures are as follows:

Chiropractic services (Medicare-covered): 98940, 98941, and 98942 when billed with the AT-modifier.
Outpatient therapies: 92507, 92508, 92526, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97799, G0283.

This applies to UnitedHealthcare Medicare Advantage nationally, excluding Dual Complete Special Needs Plans (SNP). Current prior authorization requirements in Arkansas, Georgia, South Carolina, and New Jersey for outpatient therapies continue as previously deployed and will now include Medicare-covered chiropractic services.

Prior authorization is not required for claims for the initial evaluation to be considered for reimbursement. However, prior authorization is required for the treatment plan, which specifies the number of visits.

Health care providers are required to submit the initial evaluation results and the plan of care by completing an outpatient assessment form. After the initial treatment plan is completed, if additional visits are needed, health care providers will need to submit prior authorization.

The new “Patient Summary Form (PSF)” will not be required for the initial evaluation, but will be required for subsequent treatment visits. Providers may submit a prior authorization request through the UnitedHealthcare provider portal (go to UHCprovider.com and click “sign in” at the top-right corner).

November 2024