Univera Healthcare Outpatient Physical Therapy prior authorization requirements (2026)
What Univera Healthcare generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Commercial plans. Yes. Univera Healthcare generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
Medical-necessity criteria Univera Healthcare generally applies
Outpatient physical therapy requires medical necessity for skilled care: an objective functional deficit, an individualized plan of care with measurable, time-bound goals, interventions that require the skills of a licensed therapist, and periodic re-evaluation documenting progress or the continued need for skilled intervention. Continuation or extension of visits requires documentation of ongoing medical necessity — measurable functional limitations, the skilled nature of the interventions, and the clinical rationale for continued therapy. For chronic neurological conditions such as spinal cord injury, document the need for skilled therapy to maintain function and prevent deterioration, secondary complications, or loss of function.
Source
Univera Healthcare (WNY, Excellus/Lifetime Healthcare). General outpatient-PT medical-necessity criteria — verify Univera's specific clinical policy/visit limits. Medicare Advantage line applies the Jimmo maintenance standard. Last verified 2026-06-10.
Frequently asked questions
Does Univera Healthcare require prior authorization for Outpatient Physical Therapy?
Yes. Univera Healthcare generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
What does Univera Healthcare require to approve Outpatient Physical Therapy?
Outpatient physical therapy requires medical necessity for skilled care: an objective functional deficit, an individualized plan of care with measurable, time-bound goals, interventions that require the skills of a licensed therapist, and periodic re-evaluation documenting progress or the continued need for skilled intervention. Continuation or extension of visits requires documentation of ongoing… Always confirm against the current Univera Healthcare policy.
How long does a Univera Healthcare prior authorization take?
Turnaround varies by plan and submission method. Check the Univera Healthcare portal for current timeframes.
Submitting Outpatient Physical Therapy to Univera Healthcare?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.