United Healthcare has published Medical Policy updates effective July 1, 2023 that affect Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech). The full documentation can be found here. The policy changes affect the Commercial and Individual Exchange benefit plans.
Many of the policy changes affect documentation that must be supplied to United Healthcare so it is important that you review your documentation to make sure your claims are not denied because of missing information. Below are some of the changes, please be sure to review the entire Medical Policy Change for all of the changes effective July 1 2023.
Please Note: United Healthcare has issued an addendum for these policies that take affect on August 1, 2023. The primary change has to do with Plans of Care so be sure to review the addendum as well as the original policy change.
Initial Therapy Evaluation/Initial Therapy Visit Requests
The therapy evaluation report must include all of the following:
- A statement of the member’s medical history; and
- A comparison prior level of function to current level of function, as applicable; and
- A description of the member’s functional impairment including its impact on their health, safety, and/or independence; and
- A clear diagnosis including the appropriate ICD-10 code; and
- Reasonable prognosis, including the member’s potential for meaningful and noteworthy progress; and
- Baseline objective measurements (current versions of standardized assessments), including a description of the member’s current deficits and their severity level which include:
- Current standardized assessment scores, age equivalents, percentage of functional delay, criterion-referenced scores and/or other objective information as appropriate for the member’s condition or impairment
- Standardized assessments administered must correspond to the delays identified and relate to the long- and short-term goals
- Standardized assessments results will not be used as the sole determinant as to the medical necessity of the requested initial therapy visit
- If the member has a medical condition that prevents them from completing standardized assessment(s), alternative could include:
- The therapist provides in-depth objective clinical information using task analysis to describe the member’s deficit area(s) in lieu of standardized assessments
- The therapist should include checklists, caregiver reports or interviews, and clinical observation
Plan of Care
The initial authorization for therapy must also include a plan of care (POC). The POC must be signed and dated by the referring provider (PCP) (MD, DO, PA or NP) or appropriate specialist. Providers must develop a member’s POC based on the results of the evaluation. The POC must include all the following:
- Functional or physical impairment; and
- Short and long-term therapeutic goals and objectives:
- Treatment goals should be specific to the member’s diagnosed condition or functional or physical impairment
- Treatment goals must be functional, measurable, attainable and time based
- Treatment goals must relate to member-specific functional skills and
- Treatment frequency, duration, and anticipated length of treatment session(s)
Re-Evaluations
Re-evaluations must be completed at least once every twelve months or more frequently based on state regulatory requirements to support the need for on-going services. Re-evaluations performed more often than once should only be completed when the member experiences a significant change in functional Level in their condition or functional status. The documentation must be reflective of this change. Re-evaluations must include current Standardized Assessment scores, percentage of functional delay, criterion referenced scores or other objective information as appropriate for the member’s condition or impairment. The therapy re-evaluation report must include all of the following:
- Date of last therapy evaluation; and
- Number of therapy visits authorized, and number of therapy visits attended; and
- Compliance to home program; and
- Description of the member’s current deficits and their severity level documented using objective data; and
- Objective demonstration of the member’s progress towards each treatment goal:
- Using consistent and comparable methods to report progress on long- and short-term treatment goals established
- For all unmet goals, baseline and current function so that the member’s progress towards goals can be measured and
- An updated statement of the prescribed treatment modalities and their recommended frequency/duration; and
- A brief prognosis with clearly established discharge criteria; and
- An updated individualized POC must include updated measurable, functional, and time-based goals:
- The updated POC/progress summary must not be older than 90 days; and
- If the majority of the long and short-term goals were not achieved, the plan of care must include a description of the barriers or an explanation why the goal(s) needed to be modified or discontinued and
- A revised POC that the treating therapist has not made a meaningful update to support the need for continued services will not be accepted. In addition, the notation of the percentage accuracy towards the member’s goals alone is not sufficient to establish a need for continued, Medically Necessary therapy.
Treatment Session Notes
All treatment session notes must include:
- Date of treatment
- Specific treatment(s) provided that match the CPT code(s) billed
- Start and stop time in treatment
- The individual’s response to treatment
- Skilled ongoing reassessment of the individual’s progress toward the goals
- All progress toward the goals in objective, measurable terms using consistent and comparable methods
- Any problems or changes to the POC
- Member or caregiver involvement in and feedback about home program activities
- Signature and date of the treating provider