United Healthcare recently implemented several updates to its policies regarding habilitation and rehabilitation therapy coverage, which went live on June 1. These changes aim to clarify coverage criteria, streamline documentation requirements, and ensure the provision of medically necessary services. In this article, we will summarize the major revisions made in United Healthcare’s policy, but please be sure to read the full policy here to ensure you don’t miss anything.
Coverage rationale
The previous language indicating coverage for “outpatient habilitation, rehabilitation, and maintenance therapy when medically necessary” has been replaced with a statement emphasizing that habilitation, rehabilitation, and maintenance services must be “proven and medically necessary in specific circumstances.” This change aims to provide clearer guidance on the coverage criteria.
The updated criteria instructions for medical necessity clinical coverage are outlined in the InterQual Level of Care (LOC) for Outpatient Rehabilitation and Chiropractic. Providers and billing staff should reference this to assess whether a member meets the clinical criteria for coverage. However, it is important to note that meeting these criteria does not guarantee coverage for the requested services. This clarification underscores the need for accurate, comprehensive documentation to support medical necessity.
Plan of care requirements
- Functional or physical impairments; 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,
- Treatment frequency, duration, and anticipated length of treatment session(s)
Prompt users can leverage POC requirement payer rules to ensure POCs are gathered every time for cases going forward.
Direct Access?
A patient can still come to therapy without a physician referral, but you are required to get a plan of care signed after the initial evaluation.
Treatment (daily) note requirements
Once an approved patient is being actively treated, the general requirements for treatment session notes are:
- Date of treatment
- Specific treatment(s) provided that match the CPT code(s) billed
- Total treatment time (originally “time-in, time-out”)*
- The individual’s response to treatment
- Skilled ongoing reassessment of the individual’s progress toward their 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 exercise programs
- Signature and date of the treating provider
Re-evaluation report requirements
Re-evaluations must be completed at least once every twelve months, or more frequently based on state regulatory requirements to support the need for ongoing services. The therapy re-evaluation report must include all of the following:
- Date of last therapy evaluation
- Number of therapy visits authorized, and number of therapy visits attended
- Compliance to home program
- Description of the member’s current deficits and their severity level documented using objective date
- Objective demonstration of the member’s progress towards each treatment goal
- An updated statement of the prescribed treatment modalities and their recommended frequency/duration
- A brief prognosis with clearly established discharge criteria
- An updated individualized POC must include updated measurable, functional, and time-based goals
Progress reports
The policy did not include language pertaining to progress reports for requests for continuation of treatment. It is advisable to consult the latest guidelines and reach out to United Healthcare directly to determine the current requirements for progress reporting.
Initial therapy evaluation/initial therapy visit requests
Previously, a provider (PCP) or an appropriate specialist referral was required to be on file prior to the completion of an evaluation for speech, physical, and occupational therapy. However, this requirement has been removed. Make sure your team reviews the most recent guidelines, or contacts United Healthcare to confirm the current procedure for initial therapy evaluation requests.
Conclusion
Staying informed about changes to insurance policies is crucial for healthcare professionals and providers. Healthcare practitioners should carefully review the revised policy and reach out to United Healthcare for any specific inquiries or clarifications regarding coverage requirements or documentation guidelines.
*APTA reported that United Healthcare updated this requirement in November 2023. According to the APTA, the “time-in, time-out” requirement is satisfied by documenting the total treatment time (which is on Prompt notes by default).
Disclaimer: This blog post is intended for information purposes only and should not be considered as official policy documentation. For the most accurate and up-to-date information, please refer to United Healthcare’s official policy documents or consult with the relevant authorities.
