UnitedHealthcare’s New Prior Authorization Rules for PT, OT, and ST: What Clinics Must Know

Outpatient therapy services are often a lifeline for patients recovering from injury, illness, or developmental delays. But starting November 1, 2025, UnitedHealthcare (UHC) is rolling out new prior authorization requirements for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services under its Community Plan in Kansas, North Carolina, and Virginia.

If you’re a doctor, clinic, or hospital, these changes will affect how you schedule, document, and bill therapy services for UHC members. The rules are detailed and strict—but understanding them now can save your team from denials, delays, and unnecessary stress later.

Below, we break down exactly who this applies to, what’s changing, and what you need to do differently in your documentation and billing practices.

Key Change at a Glance

• Prior authorization required for PT/OT/ST outpatient services (age ≥3) in Kansas, North Carolina, and Virginia for UHC Community Plan members, effective Nov 1, 2025.
• In North Carolina, this expands to include adults 21 and older.
• Initial evaluations are excluded from clinical review but must still be submitted for authorization.
• First 6 visits of a treatment plan are covered without clinical review if delivered within 8 weeks of the first service date. But yes—you still must submit the request.

Requests can be submitted up to 2 business days after the first service and will be retroactive if approved.

Think of it this way: UHC isn’t just looking at the start of therapy anymore—they want oversight throughout the plan of care.

Who Is Affected (and Who Isn’t)

The policy doesn’t apply to everyone. Let’s clear up the scope:

Applies to:

• UHC Community Plan members in KS, NC, VA
• Age 3 and older (in NC, also applies to those 21 and up)

Does not apply to:

• UHC Dual Complete members
• Children under 3
• Kansas only: Pediatric Care Network and LTSS programs

For front-desk staff and billing teams, this means eligibility checks at intake are more important than ever. One missed detail could send you down the wrong path.

What Providers Must Submit

To keep therapy sessions authorised and reimbursed, UHC now requires a tight packet of documents:

• Signed referral/order from a Medicaid-enrolled provider (must be obtained at or before evaluation).
• Current evaluation report and plan of care with measurable goals, frequency, and duration.
• Progress report or recent daily treatment notes showing clinical need and patient progress.

All prior authorization requests go through the UHC Provider Portal. The tricky part? Even if your patient qualifies for the 6-visit “grace” period, you still must submit that packet.

North Carolina Medicaid: Additional Rules You Can’t Miss

North Carolina adds another layer of complexity. Under NC Medicaid’s Clinical Coverage Policy 10A:

• Prior approval is required for all outpatient therapies.
• Providers must submit supporting health records proving the patient meets criteria.
• A written evaluation report must be completed within 3 months of treatment start, with annual re-evaluations for continued therapy.
• Reauthorizations must prove treatment efficacy—that means measurable, objective improvement.
• For patients under 21, EPSDT ( (Early and Periodic Screening, Diagnostic, and Treatment)) rules apply: if medically necessary, therapy beyond limits may still be covered.

In Short: North Carolina clinics must maintain thorough and measurable documentation. Vague goals like “improve mobility” won’t cut it anymore—you need quantifiable progress markers.

Why Documentation Needs a Makeover

Many therapy notes still read like quick recaps: “30 minutes of gait training, tolerated well.” Under these new rules, that’s a denial waiting to happen.

What you need to start including:

• Referral details (provider NPI, signature, date)
• Objective baseline measures (e.g., gait speed, speech clarity scores, grip strength)
• Measurable short- and long-term goals (“patient will walk 100 feet with supervision within 6 weeks”)
• Skilled intervention rationale (why therapy, not home exercise, is required)
• Daily notes that tie each session back to goals and progress

This isn’t just paperwork—it’s your defense if UHC questions medical necessity.

Can Billing Companies Help? Absolutely.

Here’s where billing experts step in, like Hello MDs, a best-rated company in medical billing. A seasoned medical billing company can:

• Handle prior auth submissions through the UHC portal within the strict 2-day window.
• Assemble documentation packets—referrals, evals, POCs, and progress notes—before submission.
• Scrub claims for coding mismatches (CPT, modifiers, POS) that trigger denials.
• Manage denials/appeals with strong clinical evidence.
• Train your staff on what documentation auditors now expect.
• Set Up Alerts in your EHR so that any UHC Community Plan patient automatically enters an “auth required” workflow.

If your in-house team is already stretched thin, this is one of those changes where outsourcing prior auth and denial management could save hours—and revenue.

Considering a Medical Billing partner? HIPAA compliant companies like HelloMDs can help you offload all these stressful and administrative tasks. Get a no obligation quotation today.

Conclusion

UHC’s new rules may feel like one more hurdle in an already complex system, but the takeaway is simple – authorization and documentation standards just got tighter.

For doctors, clinics, and hospitals, the key is to adapt quickly:

• Train staff now
• Update evaluation and note templates
• Submit authorizations on time
• Keep progress measurable

If you do, you’ll not only stay compliant—you’ll also protect your revenue stream and ensure patients don’t experience care interruptions.

Disclaimer: This blog is for informational purposes only and does not constitute medical, legal, or professional advice. While we strive for accuracy, errors or omissions may occur.