BCBSNC
On July 29, 2024, Health Network Solutions notified providers via email that BCBSNC plans to require prior authorization for most physical therapy codes for its fully insured plans starting October 1, 2024. Since then, the effective date was moved to December 1, 2024.
BCBS Prior Authorization Announcement – Effective 11/1
Please review HNS Summary Sheet. This contains lots of helpful information including how to access the Carelon portal and submit a PA request with step by step instructions.
Submitting a Prior Authorization
Check out this helpful video provided by NCCA member Liz Nieland that walks you through the process of submitting a prior authorization to Carelon via Blue-E.
Download a printable SOP of how to obtain a preauthorization.
UnitedHealthcare:
UnitedHealthcare (through its Optum subsidiary) will now require prior authorization for chiropractic and other therapy services under Medicare Advantage plans.
UnitedHealthcare (Optum) announced providers must obtain approval for defined treatment plans (request a number of visits). This policy will apply to chiropractic manipulative therapy (CMT), physical therapy, occupational therapy, and other related services, excluding the initial evaluation. Although UHC initially stated the program would apply to “multi-disciplinary offices,” the updated version indicates that it could apply to all chiropractic practices.
Advocacy Response -Utilize the Patient Advocacy Flyer
This new requirement imposes an additional administrative burden on providers and could significantly delay patient care, particularly for Medicare Advantage patients, who have chosen these plans expecting streamlined access to conservative care options.
ChiroCongress is organizing a nationwide response, and the NC Chiropractic Association is participating with a letter directly to UnitedHealthcare, voicing our concerns. They have also created a patient advocacy flyer that we encourage you to share with your patients to make sure they are informed and empowered to protect their access to essential care.
Download the Patient Advocacy Flyer
This flyer includes vital information about the prior authorization changes and guidance on how patients can advocate for themselves by contacting their insurance providers directly.
It clearly instructs your patients on how to contact Humana and UnitedHealthcare directly. It encourages them to demand respect for the treatment plans you recommend and to urge their insurers to stop the prior authorization requirement for chiropractic and other physical therapy care.
We strongly urge you to share this flyer widely to ensure that patients are informed and empowered to protect their access to essential care.
Humana:
NC Doctors Do NOT need to submit Prior Authorizations for Humana. (updated on 9/6/2024)
After multiple discussions with Humana’s Director of Clinical Coverage Policy Operations by multiple ChiroCongress key stakeholders, we have clarified that the previously announced preauthorization program for chiropractic services is limited to Florida and California only under their Medicare Advantage programs.
Key Takeaways:
- Humana Preauthorization Limited to Specific Areas: Prior authorization is only required for chiropractors in Southern Florida (Tivity) and Southern California (ASH).
- Updated Documentation: Humana has corrected its previous communication and provided updated documents. The revised Summary of Changes and the complete Preauthorization and Notification List (PAL) now accurately reflect the limited scope of the requirements. Chiropractors outside these areas do not need prior authorization for Humana Medicare Advantage plans.
You can review the updated documents through the following links:
- Preauthorization and Notification List (PAL) (Pages 5 and 6)
- Updated Summary of Changes (references to chiropractic are removed entirely)