Outpatient Therapy Services Under Kansas, North Carolina, And Virginia Medicaid
Starting Nov 01, 2025, UnitedHealthcare will require prior authorization for physical, occupational, and speech therapy for UnitedHealthcare Community Plan members ages 3 and older in Kansas, North Carolina, and Virginia. In North Carolina, this change also expands the requirement to include members ages 21 and older.
Prior authorization is required for the entire plan of care (initial eval excluded) for outpatient PT/OT/ST.
- Every visit requested must have a prior authorization on file.
- First 6 visits of the initial plan of care: covered without clinical review if all 6 occur within 8 weeks of the first
- DOS; a prior authorization request is still required.
- Medical necessity review applies to plans requesting >6 visits or that extend beyond 8 weeks.
- Submit requests up to 2 business days after the first DOS; approvals, when issued, are retroactive to the request date.
Applies to new and current therapy patients. Submit starting Oct. 1, 2025, for DOS on/after Nov 01, 2025
North Carolina: Applies to all PT/OT/ST patients, under and over 21.
Additional Information
For patients already in care, submit treatment plans for dates of service on or after Nov 01, 2025, for medical necessity review. A prior authorization request is still required to ensure claims are paid. When submitting PT/OT/ST requests, include the following documentation:
Documentation to include (PT/OT/ST):
- Signed referral obtained at the evaluation
- Current evaluation report and plan of care
- Current progress report or most recent daily treatment notes
How to submit: Use the Prior Authorization & Notification tool in the UnitedHealthcare Provider Portal.
Exclusions:
- UnitedHealthcare® Dual Complete plans
- Members under 3 years of age
- Kansas only: Pediatric Care Network and LTSS
Resources: The program FAQ covers exclusions, impacted CPT® codes, clinical examples, and the authorization/claims workflow.
