OPTUM New Prior Authorization Process

Optum released an update to the Medicare Advantage Clinical Submission process

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In order for “providers to begin treatment the same day as the member’s initial consultation when clinically appropriate and ensure additional care is provided promptly” they have revised the authorization requirement.

Starting January 13, 2025, up to the “first six visits of a member’s initial plan of care will be covered without conducting a clinical review when the first 6 visits take place within 8 weeks of the first date of service.”

Clinics will need to update their alerts and workflow to take into consideration the revised submission deadlines, visit count, time period limitations (within 8 weeks of initial visit) as well as stipulations such as the patient is new to the office, has a new condition, or has a gap in care of more than 90 days.

Please keep in mind the bigger picture. Most clinical guidelines and prior authorization policies are based on the payer’s coding and documentation audits from past claims. It is vital that providers continue to submit treatment authorizations for clinical review if more than six visits are medically necessary. This data can help in establishing medical necessity for the patient but can also impact future payer policies. When payers crunch the data and see visible evidence of medical necessity for patients that exceed six visits, they may no longer see the need for costly and time-consuming prior authorization. Be sure to tell the patient’s whole story by presenting documentation that supports medical necessity.

Not sure about your documentation standards?

Let KMC University take a closer look. Learn about some of the services we offer by booking a Free Discovery Assessment

If you are library member please visit the course titled Documentation & Coding Basics

Additional information on Medicare Advantage Prior Authorization is available.

For Information on how to submit a PSF-750 Online

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