New Prior-Authorization Requirements for Medicare Advantage Plans

Dear Chiropractic Professionals,

We want to bring your attention to significant changes regarding prior-authorization requirements that will soon impact your practice.

Beginning August 29, 2024, Humana will implement new prior-authorization protocols for chiropractic and other physical therapy services. UnitedHealthcare, through Optum, will follow suit on September 1, 2024, with similar requirements under their Medicare Advantage plans.

What Mass Chiro Has Done for You

In response to these upcoming changes, Mass Chiro’s Public Policy Initiatives (PPI) has taken decisive action on behalf of the profession, our member doctors, and the patients they serve. Mass Chiro has formally addressed our concerns to the leadership at UnitedHealthcare by sending a detailed letter to Mr. Noel, the CEO of UHC’s Medicare division. Our letter strongly advocates against these changes, emphasizing the administrative burden, potential barriers to care, and the undermining of provider judgment that these new requirements impose.

We also highlighted the lack of clarity in Optum’s definitions and criteria, which could lead to arbitrary and inconsistent application of prior-authorization rules across practices. Our goal is to protect our profession’s ability to provide timely, necessary care to patients without undue administrative hurdles.

How You Can Help

We encourage all providers to actively participate in this advocacy effort. To support your outreach, we are enclosing two important documents:

1. UHC Template Letter
2. Patient Advocacy Flyer

 

Humana and UnitedHealthcare have recently notified providers that they are implementing new prior-authorization requirements for chiropractic services under their Medicare Advantage plans. They claim that these changes are part of a broader effort to ensure the appropriate use of healthcare resources.

Key Points:

• Effective Dates:
• Humana Medicare – August 29, 2024
• UnitedHealthcare Medicare – September 1, 2024
• Affected Services:
• Humana Medicare: 98940, 98941, 98942, 98943
• UnitedHealthcare Medicare: 98940, 98941, 98942 (when billed with the AT modifier) and select physical medicine codes (if covered under the plan)
• Exclusions:
• This requirement does not apply to Evaluation and Management (E/M) services, which do not require prior authorization. Your office may need to adjust protocols accordingly, such as conducting the E/M on the initial date of service, submitting the preauthorization request, and scheduling chiropractic treatments only after the authorization has been approved.
• Impact on Providers:
• Providers must submit a prior-authorization request for the treatment plan after the initial evaluation. Failure to obtain authorization may result in claim denial, and providers will not be able to balance bill patients for these services.

Resources for Providers:

• Humana Providers: Visit the Humana Provider Coverage & Claims page for information on Preauthorization and Notifications.
• UnitedHealthcare Providers: For guidance on submitting a prior authorization request, please visit the UnitedHealthcare Notification. UHC has delegated the review process to Optum Health Solutions.

We encourage all providers to familiarize themselves with these changes and ensure that prior authorizations are obtained promptly to avoid disruptions in patient care.

Mass Chiro is currently exploring ways we can collaborate with national organizations to fight these changes. Stay tuned for more information as it becomes available.