UnitedHealthcare updated its Medicare Advantage prior authorization policy for outpatient physical therapy effective January 13, 2025. The change responded to provider feedback about administrative burden while preserving oversight on longer episodes of care.
Under the revised policy, the initial evaluation does not require prior authorization. Up to six follow-up visits that occur within eight weeks of the initial evaluation can proceed without a clinical review. This applies to new authorization requests on or after the effective date.
You still must submit a prior authorization request for the entire plan of care. Even when the first six visits qualify for the streamlined path, the submission must list the total requested visits and duration. The shortened form available in the UHC provider portal often suffices for requests of six or fewer visits over eight weeks.
Community Plan prior authorization rules expanded in late 2025. Kansas, North Carolina, and Virginia added requirements effective November 2025. Practices in those states should verify current rules through the portal before scheduling.
Services that fall outside the six-visit window or exceed the eight-week period continue to require full clinical review. This includes requests for additional visits beyond the initial streamlined block and any plan that projects care past the eight-week mark.
Portal submission remains the required method for most UHC Medicare Advantage plans. Fax and phone requests receive limited acceptance. The portal prompts for specific CPT codes, total visits, and functional goals. Incomplete submissions trigger requests for additional information and delay the start of care.
When an authorization request receives denial, you have the right to appeal. The denial letter states the reason and the appeal deadline. Successful appeals typically include updated progress notes that demonstrate medical necessity beyond what the initial submission contained. Include measurable functional gains or clear barriers that justify continued skilled intervention.
Many practices now run a pre-submission checklist that confirms the eight-week window, visit count, and required documentation before the therapist completes the plan of care. This reduces back-and-forth with the payer and shortens time from evaluation to first authorized visit.
You can find the current prior authorization list and submission instructions on the UHC provider portal under the Medicare Advantage resources section. Policies continue to evolve, so checking the portal for each new Medicare Advantage patient remains the most reliable approach.
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