How to work with UHC Medicaid in Florida for Occupational Therapy Coverage

Jul 08, 2023

United healthcare medicaid is an MMA plan in which the patient has zero responsibility and the referrals and authorizations are obtained from the primary care office. A patient referred for occupational therapy services to a clinic in network with UHC Medicaid requires the following steps for coverage: 

1. A referral on the portal in which the primary care inputs their NPI referral to your individual NPI referring clinician. 

2. A prior authorization code of 97165, 97166 or 97167. Now here is what we have learned. All of these codes are reimbursed identically. We will request a 97165 or 97166 typically based on the medical complexity of the child and review of the referral. 

3. Most primary care offices do not know to send you what we call an A# for box 23 on the CMS1500. Without this A number you are not paid for services if the clinic performs the evaluation prior to authorization. It is very challenging to retro this A# and receive payment. Our recommendation is do not see the patient prior to receiving the A#. 

Once authorization for the evaluation only is obtained the clinic can then schedule the evaluation. 

What is included in the evaluation?

1. An objective assessment: A sensory processing measure will suffice if the child is unable to participate or the therapist unable to obtain other objective measures. 

2. A plan of care. The therapist will recommend a desired number of treatment visits per week and duration of plan of care. A common example is 2x week at 60 minutes for 6 months. The plan of care is then faxed to the primary care physician for sign off. 

Who is responsible for authorization of treatment?

1. The clinic is responsible. 

2. Visit and login as a clinic. 

3. Upload the POC, the physician referral and complete the questionnaire with the patient. 

4. Wait 48-72 hours. 

5. An authorization will be uploaded and marked as complete for your clinic to download and an email will be sent to your clinic.

How do I bill? Billing via UHC medicaid is completed with the following boxes on the CMS1500 form

1. Box 17 and 17b: Physician and NPI

2. Box 24J Individual Clinician who must be credentialed with your group UHC plan and listed on your group insurance plan. 

3. Box 24D: Occupational therapy modifier is GO

4. Box 23: Authorization Number obtained for treatment. 

Next steps:

1. Schedule your patient for treatment and make progress! 

Reimbursement rates can be found based on ACHA fee schedule for occupational therapy. 

97530 @ 30 minutes is $35.72 in 2023. 

How long until I am paid:

Turn around time for UHC Medicaid plan is typically within 7 days if a clean authorization and transition went through. 

Would you like to purchase our template in word document and input your own logo! Visit our product page and link below.

Lauren Meffen MA CCC/SLP, CLT

Speech Language Pathologist SA#9770