Prior authorization remains one of the most common points of friction in outpatient physical therapy billing. Understanding payer-specific rules helps you submit complete requests and reduce denials.

UnitedHealthcare Medicare Advantage made notable changes effective January 2025. Up to six follow-up visits after the initial evaluation can proceed without a full clinical review when visits occur within eight weeks. You still submit a request for the full plan of care. The initial evaluation itself does not require prior authorization in most cases.

Cigna, Aetna, and many Blue Cross Blue Shield plans maintain their own processes. Requirements often differ by state and specific plan. Some plans require authorization after a set number of visits. Others review the entire episode upfront. Check each payer’s provider portal for current forms and turnaround times.

Community Plan expanded its prior authorization footprint in several states. Kansas, North Carolina, and Virginia saw updates effective November 2025. These changes affect how you document medical necessity for Medicaid-managed care patients.

Documentation that supports the plan of care remains essential. Include measurable goals, functional limitations, and expected visit frequency. Missing or vague notes frequently trigger denials or requests for additional information.

The 8-minute rule still governs timed codes. Pair it with proper use of GP, GO, or GN modifiers when required. Payers cross-check these elements during review.

You can reduce delays by verifying eligibility and authorization status before the first visit. Many practices now run real-time checks through clearinghouses or payer portals. This step prevents claims from hitting the “no auth on file” wall later.

When a denial arrives, review the exact reason code. Common triggers include incomplete plans of care, missing progress notes, or visits that exceed the authorized amount. Resubmit with the missing elements rather than appealing immediately in many cases.

Link your internal workflow to the revenue cycle management process described at /revenue-cycle-management/. Clear authorization tracking belongs inside your daily billing routine.

Staying current with each payer’s portal and policy updates protects your revenue. Set calendar reminders to review major payer bulletins quarterly.

Get a free revenue cycle assessment at therapyrevenuepros.com/contact/