How to request prior authorization / notification

Prior Authorization is not a guarantee of benefits or payment at the time of service. Registered users of the secure provider portal website can log in and submit an electronic preauthorization request; call the number on the member's ID card for portal information or contact your Provider Relations Representative for assistance.

• Submit electronic preauthorization via the secure provider portal (registered users).
• Call number on member ID card for portal access information.
• Contact Provider Relations Representative for additional assistance.

Notification requirements for discharge planning and care coordination

Notification is requested for certain services to assist with discharge planning, care coordination, and case management. All services must be medically necessary and appropriate and meet Texas Medicaid Provider Procedures Manual / BSWHP coverage criteria where applicable.

• Notify the plan for services that require notification to support discharge planning, care coordination, and case management.
• Ensure services meet medical necessity and applicable coverage criteria.

Arthroscopy and shoulder procedure codes (effective 1/1/2024)

The following shoulder arthroscopy CPT codes are subject to prior authorization with an effective date of 1/1/2024: 29805–29828 (individual codes listed in the plan file).

• Examples include 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828 (effective 1/1/2024).
• Verify specific code entries and effective dates in the prior authorization list before submission.

Hip and knee arthroscopy procedure codes (effective 1/1/2024)

Hip and knee arthroscopy CPT codes are subject to prior authorization with an effective date of 1/1/2024: see codes 29860–29916 and associated entries in the list.

• Examples include 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29888, 29889, 29914–29916 (effective 1/1/2024).
• Confirm exact code and effective date on the prior authorization list prior to providing services.

Cardiac, implantable monitoring, valve and selected venous codes (mixed effective dates)

Selected cardiac, implantable monitoring, valve, and venous procedure codes are subject to prior authorization; effective dates are primarily 1/1/2024 with some venous adhesive/sclerosant codes effective 7/1/2025.

• Cardiac/monitoring/valve examples: 33289, 33365–33366, 33477 (effective 1/1/2024).
• Selected venous procedures: 36465 and 36466 (injection of non‑compounded foam sclerosant) effective 7/1/2025; 36470–36474 effective 1/1/2024.

Bariatric and gastric procedure codes (effective 1/1/2024)

Bariatric and gastric procedure CPT codes require prior authorization with an effective date of 1/1/2024; consult the list for full code details.

• Examples include 43644–43648, 43659, 43770–43775, 43845–43888 (effective 1/1/2024).
• Check the plan list for specific procedure variants and effective dates before scheduling.

Neurosurgical, spine and pain-management procedure codes (effective 1/1/2024)

Neurosurgical, spinal, and pain-management device/procedure codes are subject to prior authorization with an effective date of 1/1/2024; consult the list for complete code set.

• Examples include neurostimulator and spinal procedure codes such as 61863, 61867, 61885–61886, 62320–62327, 62350–62361, 63001–63051, 63017, and related codes (effective 1/1/2024).
• Verify each code and its effective date on the prior authorization list before performing procedures.

Prior authorization/notification requirement — code list (partial)

This excerpt enumerates CPT and other procedure codes that are included on the UHC linked plans prior authorization/notification list and therefore require prior authorization or notification as indicated in the list entries (effective dates shown per code).

• Codes in the excerpt are subject to prior authorization/notification with 1/1/2024 as the predominant effective date.
• Verify member eligibility and plan-specific requirements at time of service.

Code list — prior authorization/notification (overview)

The UHC Linked Plans Prior Authorization/Notification List enumerates CPT, HCPCS, and proprietary laboratory/procedure codes that are subject to prior authorization or notification, with effective dates indicated for each entry.

• The full list and online authorization submission tools are available on the Baylor Scott & White Health Plan service portal.
• Benefits and payment are dependent on member eligibility, plan limits, and medical necessity review.

Prior Authorization/Notification Codes List (excerpt) — U/T/CPT entries

Selected U‑, T‑ and CPT‑series entries and short service descriptions are included in the prior authorization/notification roster; these codes are subject to authorization/notification requirements under UHC linked plans (see list for details and effective dates).

• Examples include proprietary genomic assay codes (0005U, 0018U, 0022U, 0026U) and genomic CPT codes (81229, 81415, 81425) with effective dates shown.
• Confirm exact code descriptions and effective dates on the plan list prior to submission.

Code list — prior authorization/notification (CPT/HCPCS/proprietary codes)

The list includes numerous CPT and HCPCS codes subject to prior authorization/notification across service categories (imaging, radiation, molecular testing, ambulatory transport, durable medical equipment, etc.); review the plan roster for specific codes and effective dates.

• HCPCS/administrative examples: A0430–A0436 (air ambulance), E0471, E0483, and power wheelchair K‑codes (K0848–K0857) with effective dates.
• Imaging and radiation entries (77048, 77049, 77371–77373, 77402, 77407) are included with effective dates indicated.

Prior Authorization/Notification Codes List (excerpt) — U/T/CPT short descriptions

This excerpt lists U‑codes, T‑codes, CPT codes and short service descriptions (for example, genomic assays and specialized diagnostics) that are subject to prior authorization/notification requirements; effective dates accompany each entry.

• Examples: 0005U, 0018U, 0022U, 0026U (proprietary genomic codes) and S‑/T‑codes such as S1040, S3854, S3865, S8037 (effective 1/1/2024 unless otherwise indicated).
• Verify the complete code entry and effective date in the plan list before requesting authorization.

Selected HCPCS and related codes subject to prior auth/notification

Selected HCPCS and related administrative procedure codes appear on the prior authorization/notification list with effective dates; these include ambulance transport, oxygen/respiratory devices, and certain device/drug implant codes.

• Examples: A0430, A0431, A0435, A0436 (air ambulance); E0471, E0483 (respiratory/oscillation devices); C2624 and C9309 (implantable devices/drugs).
• Confirm effective date and notification/prior authorization requirement for each HCPCS code in the list.

Genomic and molecular testing CPT codes (subject to prior auth/notification)

Genomic and molecular test CPT codes are included in the prior authorization/notification list with effective dates; these entries require review and authorization prior to service.

• Examples include 81229 (CGH microarray), 81415 (Exome sequence analysis), 81425 (Genome sequence analysis), 81432–81437 (panel codes) — effective 1/1/2024.
• Proprietary genomic assay codes (0005U, 0018U, etc.) are also listed with effective dates.

J‑code injectable drugs and biologics subject to prior auth/notification

An extensive list of J‑codes for injectable drugs, biologics, and gene therapies are included on the prior authorization/notification list and require prior authorization; effective dates are shown for each code.

• Selected examples: J0129, J0174, J0179, J0217–J0225, J0256–J0257, J1299, J1429, J1442, J1551–J1569, J9173, J9271, etc.
• Review the list for the precise J‑code, description, and effective date prior to submission.

Injectable drug prior auth/notification list (partial)

Injectable drug J‑codes listed in the plan file are subject to prior authorization/notification; consult the list for specific codes and effective dates before administering or billing.

• Examples include J9173 (durvalumab), J9176 (elotuzumab), J9177 (enfortumab vedotin) — all shown with effective dates (primarily 1/1/2024).
• Ensure prior authorization is obtained when required; authorization does not guarantee payment.

Durable medical equipment (K/L codes) subject to prior auth/notification

Durable medical equipment K‑ and L‑code groups (power wheelchairs and related products) are included on the prior authorization/notification list with effective dates; prior authorization is required for listed items.

• Examples include power wheelchair codes K0848–K0857 and related entries (effective dates shown, typically 1/1/2024).
• Verify equipment-specific requirements and clinical documentation expectations when requesting authorization.