CurrentColorado Rocky Mountain Health PlansPolicy N/A

Advance Prior Authorization Requirements for Neighborhood Health Partnership

Lists the categories, CPT/HCPCS codes, and instructions for obtaining advance prior authorization for in-network services for Neighborhood Health Partnership plan members; affects participating providers and facilities performing listed services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAdvance Prior Authorization Requirements for Neighborhood Health Partnership

Policy CodePolicy N/A

Change TypeNo material changes — administrative update only

Effective DateJul. 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification app on UnitedHealthcare Provider Portal or call 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jul. 1, 2024effective date

Portalonline submission

Excludedemergency care

Multipleexample PA categories

877-842-3210NHP phone

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Advance Prior Authorization Coverage Criteria

Advance prior authorization coverage criteria

Advance prior authorization is required for the following categories and listed CPT/HCPCS codes for NHP members, unless otherwise noted. Emergency and urgent care are excluded.

Advance prior authorization is required for the categories and codes listed below unless an exception is specified.

CPT / HCPCS / ICD-10 Code Listings

Covered CPT codes — Arthroscopy (selected examples)CPTCovered

29805	Arthroscopy, shoulder, diagnostic
29806	Arthroscopy, shoulder, surgical; synovectomy
29807	Arthroscopy, shoulder, surgical; debridement
29819	Arthroscopy, shoulder, surgical; chondroplasty
29820	Arthroscopy, shoulder, surgical; with capsulorrhaphy
29821	Arthroscopy, shoulder, surgical; with subacromial decompression
29822	Arthroscopy, shoulder, surgical; with rotator cuff repair
29823	Arthroscopy, shoulder, surgical; with distal claviculectomy
29824	Arthroscopy, shoulder, surgical; biceps tenodesis
29825	Arthroscopy, shoulder, surgical; superior labrum repair

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Covered CPT codes — Arthroplasty / Major joint replacement (selected examples)CPTCovered

23470	Arthroplasty, shoulder; resurfacing
23472	Arthroplasty, shoulder; total
23473	Arthroplasty, shoulder; with cuff repair
23474	Arthroplasty, shoulder; revision
24360	Arthroplasty, elbow; total
24361	Arthroplasty, elbow; partial
24362	Arthroplasty, elbow; revision
24363	Arthroplasty, elbow; complex
24365	Arthroplasty, forearm
24370	Arthroplasty, forearm; revision

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Covered CPT codes — Bariatric surgery and related GI proceduresCPTCovered

43644	Laparoscopy, gastric bypass
43645	Laparoscopy, gastric bypass w/roux-en-y
43659	Revision of bariatric procedure
43770	Laparoscopy, gastric restrictive procedure
43771	Laparoscopy, gastric restrictive w/adjustable band
43772	Revision of gastric restrictive procedure
43773	Laparoscopy, gastrectomy for obesity
43774	Laparoscopy, sleeve gastrectomy
43775	Laparoscopy, gastric bypass small bowel
43842	Laparoscopy, gastric bypass, roux-en-y

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Covered HCPCS / J-codes — Cancer supportive care drugs (selected)HCPCSCovered

J1442	Filgrastim (Neupogen)
J1447	Tbo-filgrastim (Granix)
J1448	Trilaciclib (Cosela)
J1449	Pegfilgrastim biosimilars (example)
J2506	Pegfilgrastim (Neulasta)
J2820	Sargramostim (Leukine)
Q5101	Filgrastim-sndz (Zarxio)
Q5110	Filgrastim (biosimilar)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5122	Pegfilgrastim-apgf (Nyvepria)

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Covered CPT/HCPCS codes — ENT / Sinus / Nasal (selected)CPTCovered

31240	Nasal/sinus endoscopy, diagnostic
31253	Nasal/sinus endoscopy, surgical; with ethmoidectomy
31254	(series placeholder)
31259	Nasal/sinus endoscopy, additional procedures
31267	Endoscopic sinus surgery extended
31276	Nasal/sinus endoscopy with repair
31287	Endoscopic sinus surgery, revision
31288	Endoscopic sinus surgery, complex
31296	Endoscopic sinus surgery, add-on
31297	Endoscopic sinus surgery, add-on

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Covered CPT/HCPCS codes — Endoscopy (Upper GI) EGD seriesCPTCovered

43200	Esophagoscopy, rigid or flexible; diagnostic
43201	...series
43205	Esophagoscopy with biopsy
43211	EGD with removal foreign body
43214	Esophagogastroduodenoscopy with control of bleeding
43215	EGD with dilation
43216	EGD with stent placement
43220	EGD with sphincterotomy
43226	EGD with mucosal resection
43233	EGD with transendoscopic therapy

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Covered HCPCS / DME codes (selected)HCPCSCovered

E0194	Custom wheelchair accessories
E0265	Stair lift
E0266	Stair chair; platform
E0277	Van lift
E0296	Motorized scooter
E0297	Motorized scooter replacement
E0300	Patient lift
E0302	Hoyer lift
E0304	Overhead lift
E0328	Power wheelchair, group 2

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Covered HCPCS codes — Miscellaneous / SuppliesHCPCSCovered

A7025	Custom fabricated orthosis
A7026	Custom fabricated prosthesis
S2095	Enteral formula
G6001	Radiation therapy planning (G6001)
G6002	Radiation therapy planning (G6002)
G6003	Radiation therapy planning (G6003)
G6004	Radiation therapy planning (G6004)
G6005	Radiation therapy planning (G6005)
G6006	Radiation therapy planning (G6006)
G6007	Radiation therapy planning (G6007)

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Covered CPT codes — Plastic / Dermatologic (selected skin excision flaps)CPTCovered

11404	Excision, benign lesion; complex, 1.1-2.0 cm
11406	Excision, benign lesion; complex, 2.1-3.0 cm
11420	Excision, malignant lesion; intermediate, 0.5 cm or less
11421	Excision, malignant lesion; intermediate, 0.6-1.0 cm
11422	Excision, malignant lesion; intermediate, 1.1-2.0 cm
11423	Excision, malignant lesion; intermediate, 2.1-3.0 cm
11424	Excision, malignant lesion; intermediate, 3.1-4.0 cm
11426	Excision, malignant lesion; intermediate, 6.1-7.0 cm
11442	Excision, malignant lesion; trunk, arms, legs, 1.1-2.0 cm

Covered CPT/HCPCS — Miscellaneous procedural and pain management codes (selected)CPTCovered

20552	Injection(s); single tendon sheath
20553	Injection(s); single or multiple trigger points
27096	Injection, hip; trochanteric bursa
30410	Rhinoplasty, primary
30420	Rhinoplasty, secondary
30430	Rhinoplasty, major revision
30435	Rhinoplasty; reconstructive
30450	Septoplasty
30460	Septorhinoplasty
30462	Septorhinoplasty complex

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How Providers Should Request Prior Authorization

Prior Authorization

How Providers Should Request Prior Authorization

To request prior authorization or notification, providers should use the Prior Authorization and Notification app on the UnitedHealthcare Provider Portal (UHCprovider.com) as the primary submission method. After signing in, select the Prior Authorization and Notification app tile on your Provider Portal dashboard. If needed, prior authorization requests may also be submitted by phone.

Online submission via UnitedHealthcare Provider Portal → Prior Authorization and Notification app (preferred).
Phone submission options: 888-397-8129 for general prior authorization requests; 877-842-3210 for Neighborhood Health Partnership (NHP) Medical Management and congenital heart disease case starts; 866-889-8054 for cardiology-related prior authorizations and Gastroenterology (endoscopy) inquiries.
For Radiology/Cardiology/Oncology/Radiation/Gastroenterology endoscopy prior auths, use the Radiology, Cardiology, Oncology, Radiation Oncology, and Gastroenterology Endoscopy tile on the Provider Portal dashboard (or call 866-889-8054).

Note

Alternate contact information

Definitions and Key Terms

inv-102: Definition — Advance prior authorization (providers must complete PA prior to listed services except emergent/urgent)

DefinitionAdvance prior authorization is the review requirement that providers must complete prior to performing listed services for NHP members, except in emergent or urgent situations.

When requiredRequired for the procedure and service categories listed in this document for NHP plan members in outpatient and inpatient settings unless otherwise noted.

ExceptionNot required for emergency or urgent in- and out-of-area care.

inv-103: Outpatient injectable chemotherapy and supportive agents — definition/context for cancer supportive care injectables

DefinitionOutpatient injectable chemotherapy and certain supportive agents that require prior authorization when administered in an outpatient setting for cancer diagnoses (examples include filgrastim, pegfilgrastim, trilaciclib).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAdvance Prior Authorization Requirements for Neighborhood Health Partnership

Policy CodePolicy N/A

Change TypeNo material changes — administrative update only

Effective DateJul. 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification app on UnitedHealthcare Provider Portal or call 877-842-3210.

SourceLink

On This Page

How to obtain authorization: submit requests via the Prior Authorization and Notification app on UHCprovider.com or call the numbers provided (see provider actions).

Alternate contact information and submission routes are available for specialty areas and specific programs. Use the phone numbers below when directed by the policy or when portal access is not available.

General prior authorization phone: 888-397-8129.
NHP Medical Management / to start ESRD dialysis case management and utilization process: 877-842-3210.
Cardiology prior authorization phone (participating physicians for outpatient and office-based procedures): 866-889-8054.
For congenital heart disease services or to start a case: call 877-842-3210 or the notification number on the member's ID card.

Billing Rule

Durable medical equipment / Glucose monitors

Durable medical equipment (DME), orthotics and prosthetics may require prior authorization when the retail purchase or cumulative rental cost exceeds $1,000. Continuous glucose monitoring (CGM) and related devices require prior authorization and, for some HCPCS, a Type 2 Diabetes diagnosis is a condition of coverage.

DME threshold: purchase or cumulative rental cost > $1,000 requires prior authorization; some home health care services may qualify under DME but are not subject to the $1,000 threshold.
Orthotics and prosthetics: prior authorization required only for codes listed with a retail purchase or cumulative rental cost > $1,000.
Glucose monitors / CGM: codes include A9276, A9277, A9278, E0787, E2102, E2103; some CGM approvals require a Type 2 Diabetes diagnosis.
For questions about Optum-contracted PT/OT prior authorization or network status, contact OptumHealth Physical Health: 888-329-5182.

Prior Authorization

Diagnosis codes requiring prior authorization

Certain diagnosis codes (especially malignant melanoma and non-melanoma skin cancer codes) require prior authorization for associated procedures and services. Providers should check the policy lists for specific ICD-10 codes that trigger prior authorization.

Examples of diagnosis codes requiring prior authorization: C43.* (melanoma subcodes), C44.* (non-melanoma skin cancer subcodes) — see policy lists for full enumerations and code-level mapping.
Some procedure groups reference diagnosis-based notification/prior authorization (for example, bariatric surgery has specific obesity diagnosis codes that require notification/PA).

Prior Authorization

How to submit prior authorization requests (Gastroenterology)

Gastroenterology (including screening colonoscopy and other endoscopy procedures): submit prior authorization requests via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal, using the Radiology/Cardiology/Oncology/Radiation Oncology/Gastroenterology Endoscopy tile. Alternatively, call 866-889-8054 for assistance.

Screening colonoscopy codes (example: G0105, G0121 and listed CPT codes) — site-of-service rules may apply; verify SOS when submitting.
Use the Gastroenterology prior authorization area on the Provider Portal for code-level requirements and documentation upload.
If portal submission is not possible, call 866-889-8054.

Prior Authorization

ESRD dialysis case management initiation

For members with end-stage renal disease (ESRD) who require dialysis case management, providers must contact NHP Medical Management to initiate case and utilization management prior to out-of-network dialysis services.

Call NHP Medical Management at 877-842-3210 to start ESRD dialysis case management and utilization management process.
Advance prior authorization is required when members are referred to an out-of-network dialysis provider.

Prior Authorization

Injectable medications prior authorization

Injectable and infused medications administered in outpatient settings frequently require prior authorization. This includes oncology injectable chemotherapy agents (J9000–J9999), many J‑codes listed in the policy, and specific injectables billed under miscellaneous or Q codes.

Injectable chemotherapy drugs (J9000–J9999) require prior authorization when administered in an outpatient setting; includes intravenous, intravesical and intrathecal routes for cancer diagnoses.
Selected J-codes specifically listed across the policy (for example J0256, J0257, J1442, J1447 and many others) require prior authorization — refer to the J/HCPCS mappings in the policy for code-specific requirements.
Biologics, immune globulins, enzyme therapies and other specialty injectables often have specific prior authorization/predetermination pathways and may require predetermination for non-participating providers.
For predetermination or specialty pharmacy transactions, providers may be directed to UnitedHealthcare Provider Portal > Specialty Pharmacy Transactions tile or to call 877-842-3210.

Prior Authorization

How to obtain prior authorization / predetermination

Predetermination (clinical review before service) is recommended for many newly marketed or high-cost injectable medications. Non-contracted providers may be instructed to submit a predetermination request prior to providing infusion/injection services.

Predetermination is recommended for drugs on UnitedHealthcare's Review at Launch for New to Market Medications list.
Non-PAR (non-participating) providers should submit a predetermination request via UHCProvider.com when instructed in the policy.
For Specialty Pharmacy or high-cost medications, submit via the Specialty Pharmacy Transactions tile on the Provider Portal or call 877-842-3210 for Commercial plans.

Note

Payer attribution statement

This policy and the associated prior authorization administration are attributed to UnitedHealthcare and affiliated entities for coverage and administrative functions; insurance coverage and administrative services may be provided by UnitedHealthcare Insurance Company and various UnitedHealthcare affiliates. Providers should follow UnitedHealthcare Provider Portal submission workflows and contact the plan-specific phone numbers when applicable.

Payer attribution: Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. or their affiliates; plan administration and services may be provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates.
Health Plan coverage references include UnitedHealthcare of Colorado, Inc. and other state-specific UnitedHealthcare entities — verify the member's plan and use the notification/phone number on the member's ID card when applicable.
Providers must use the UnitedHealthcare Provider Portal submission tools and follow affiliate-specific instructions in the policy for Commercial vs other product types.

Prior Authorization

J-/HCPCS code mappings and prior authorization references

The policy contains extensive J‑code and HCPCS mappings that link specific injectable medications and device codes to prior authorization requirements. Providers must consult the code lists in the policy for the exact J/HCPCS codes requiring prior authorization and for indications (oncology vs non‑oncology) that affect requirement.

Many J‑codes (J0141, J0202, J0256, J1442, J1447, J2506, J718x series, J72xx series, J9xxx series, etc.) are listed with specific prior authorization instructions — refer to the policy code mapping sections to determine oncology vs non-oncology diagnosis requirements.
Some codes require prior authorization across both oncology and non-oncology diagnoses (see the policy footnotes for exceptions and oncology guidance).
Unclassified/temporary codes (C9399, J3490, J3590) require notification/prior authorization only for specific products (e.g., Nulibry™, Rivfloza™, Revcovi™).

Prior Authorization

Pain management injections & orthotics

Pain management injections and orthotic devices may require prior authorization, with orthotics subject to the DME/prosthetic retail-purchase or cumulative rental cost threshold.

Prior authorization required for many pain management injection codes and related services — consult the policy lists for the exact CPT/HCPCS codes.
Orthotics: prior authorization required only for orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000.
If orthotic or DME services exceed the monetary threshold, submit prior authorization via the Provider Portal or call the appropriate prior authorization phone number.

Prior Authorization

Prior authorization process for advanced outpatient imaging

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) requires prior authorization. The ordering provider is responsible for requesting prior authorization before scheduling the procedure.

Care providers ordering advanced outpatient imaging must request prior authorization/notification prior to scheduling.
Submit requests online via UnitedHealthcare Provider Portal → Prior Authorization and Notification app and select the Radiology authorization workflow.
For Commercial radiology prior authorization code lists and details visit UHCprovider.com/priorauth > Radiology > Commercial or use the Radiology tile on the Provider Portal.

Prior Authorization

Site-of-service prior authorization rules

Site-of-service (SOS) prior authorization rules: certain procedures require review of the site of service as part of the prior authorization. Some procedures are subject to SOS review unless performed in specific states or in certain outpatient facilities (e.g., ASCs) where authorization may not be required.

Arthroscopy, foot surgery and other listed procedures require prior authorization and may trigger a site-of-service (SOS) review; exceptions may apply in AK, MA, PR, RI, TX, UT, VI, WI.
Some procedures (e.g., certain ENT or minor procedures) may not require prior authorization if performed at a participating Ambulatory Surgery Center (ASC) — verify SOS guidance per code.
When SOS review applies, the prior authorization process will include evaluation of whether the procedure is appropriate in the requested outpatient hospital/ASC/office setting.
For screening colonoscopy and other listed codes, SOS outpatient designation and prior authorization instructions are provided in the Gastroenterology section.

Note

Payer / administrative entities

UnitedHealthcare and its affiliates administer coverage and prior authorization processes referenced in this policy. Administrative services may be performed by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC, or other affiliates; behavioral health products may be provided by United Behavioral Health or its affiliates. Providers should use the plan- and product-specific submission workflows on UHCprovider.com and contact the phone numbers listed in this section for plan-specific guidance.

Insurance coverage and plan administration are provided by UnitedHealthcare Insurance Company and various UnitedHealthcare affiliated entities; confirm the member's specific plan and affiliate.
Administrative services and specialty functions (e.g., pharmacy, utilization management, PT/OT authorization) may be provided by Optum or other UnitedHealth Group affiliates — follow instructions specific to the product (Commercial, NHP, etc.).
Use the Provider Portal workflows and affiliate contact numbers (listed above) for prior authorization and predetermination submissions.

Includes specified J- and Q-codes such as J1442, J2506, J1447, J1448 and multiple Q-codes listed in the cancer supportive section.

SubmissionPrior authorization/predetermination requests must be submitted via the Prior Authorization and Notification app on the UnitedHealthcare Provider Portal or by the phone numbers provided.

inv-104: UHC Prior Authorization Portal — definition/reference for the Prior Authorization and Notification app

Tool namePrior Authorization and Notification app on UnitedHealthcare Provider Portal (UHCprovider.com).

How to accessSign in to UHCprovider.com, click the UnitedHealthcare Provider Portal button, then select the Prior Authorization and Notification app tile on the dashboard.

Alternate submissionSome specialty lines provide phone submission options (see document for specific numbers); advanced imaging/radiology uses the Radiology/Oncology tiles as directed.

inv-105: Cancer supportive HCPCS — HCPCS drug codes (J-/Q-codes) described as cancer supportive agents

DefinitionHCPCS J- and Q-codes that represent cancer supportive care agents (colony-stimulating factors, supportive biologics and select oncology supportive injectables).

Representative codesExamples in the document include J1442 (filgrastim), J2506 (pegfilgrastim), Q5110/Q5125/Q5122 (filgrastim/pegfilgrastim biosimilars) and J1448 (trilaciclib).

PA expectationThese HCPCS/J-codes require prior authorization when administered in outpatient settings as listed in the cancer supportive section.

inv-106: Clinical trials — definition mention in document

DefinitionClinical trials: a rigorously controlled study of a new drug, medical device or other treatment on eligible human subjects subject to oversight by an Institutional Review Board (IRB).

PA stanceClinical trials are noted in the document with prior authorization requirements where specified (clinical-trial codes referenced).

inv-107: Cochlear and other auditory implants — definition/description of cochlear implants

DefinitionCochlear and other auditory implants: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational speech.

CodesDocument maps S9988/S9990/S9991 to procedure codes 69710, 69714, 69930 and device HCPCS L8614.

PA requirementPrior authorization is required for cochlear and other auditory implants as indicated in the policy.

inv-108: Insurer/Administrator — UnitedHealthcare affiliates referenced as insurer/administrator

Entities listedInsurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. or their affiliates.

Administrative servicesAdministrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates.

Behavioral health vendorsBehavioral health products provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or affiliates.

inv-109: Prior authorization — definition/term usage

TermPrior authorization: a requirement that providers obtain review and approval before performing listed procedures or services.

ScopeThe document states prior authorization is required for listed procedures and codes in all states unless otherwise noted.

ExceptionsExceptions and state-specific rules are noted elsewhere in the document (e.g., certain SOS exceptions).

inv-110: DME — durable medical equipment definition/context

DefinitionDurable medical equipment (DME): equipment and supplies listed by HCPCS subject to prior authorization when listed; some home health services may qualify as DME.

ThresholdDME items with retail purchase or cumulative rental cost of more than $1,000 require prior authorization.

Home health exceptionSome home health care services that qualify under DME are not subject to the $1,000 threshold per the document.

inv-111: ESRD dialysis services — definition/context for dialysis services and PA requirement

DefinitionEnd-stage renal disease (ESRD) dialysis services: services for treating ESRD, including outpatient dialysis; prior authorization required when members are referred to an out-of-network dialysis provider.

ProcessProviders should call NHP Medical Management at 877-842-3210 to start case management and utilization management for ESRD dialysis referrals to out-of-network providers.

inv-112: SOS — site-of-service abbreviation/definition

AbbreviationSOS = Site of Service.

MeaningIndicates the location where a procedure is performed and whether prior authorization and/or SOS rules apply (e.g., outpatient hospital vs office/ASC).

ApplicationDocument repeatedly designates many procedures as 'SOS - Outpatient' and includes SOS-specific rules for prior authorization and exceptions.

inv-113: Prior authorization for outpatient/home services — definition/context for services in outpatient settings including home

ScopePrior authorization for outpatient/home services: certain home health and injectable services administered in outpatient settings (including the member's home) require prior authorization.

ExamplesInjectable medications (e.g., J0256, J0257) and home-administered medications referenced in the colonoscopy screening section require prior authorization.

SubmissionProviders must submit requests via the Prior Authorization and Notification app or follow the procedure-specific submission directions in the policy.

inv-114: member's home — definition/context where PA may be required

DefinitionMember's home: the location context where prior authorization may be required for services or medications delivered at the member's residence.

Document noteThe colonoscopy screening section explicitly references prior authorization for injectable medications when administered in the member's home.

SubmissionTo submit a prior authorization for home-administered services, use the Provider Portal/PA app as directed in the policy.

inv-115: Colonoscopy - Screening ONLY (SOS Only Applies) — term reference for screening colonoscopy heading

TermColonoscopy - Screening ONLY (SOS Only Applies): heading used in the document to denote screening colonoscopy codes and associated SOS rules; prior authorization applies as noted.

CodesLists screening colonoscopy CPT/HCPCS codes (e.g., G0105, G0121, 45386, 45388, 45398) with SOS annotations in the policy.

SOS noteSite-of-Service (SOS) rules may apply to these screening colonoscopy codes; submission instructions reference the Radiology/Cardiology/Oncology/Gastroenterology tiles or phone 866-889-8054.

inv-116: Predetermination request — definition/reference to predetermination

DefinitionPredetermination request: the process for submitting requests (for certain IV/infused medications or non-PAR provider cases) by logging into UHCProvider.com and using the provider portal's predetermination flow.

When usedUsed for injected/infused or intramuscular medications listed in the colonoscopy screening/injectable medication sections (document lists many J/HCPCS codes where predetermination is indicated).

inv-117: Payer attribution — insurance/payer attribution statement described

StatementPayer attribution: insurance coverage and administrative service attributions list UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. and various UnitedHealthcare affiliates.

Administrative servicesAdministrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates are referenced in the policy.

inv-118: MR-guided focused ultrasound — MRgFUS definition

DefinitionMR-guided focused ultrasound (MRgFUS): a procedure (0072T) to treat uterine fibroid that requires prior authorization and is covered for certain benefit plans subject to plan-specific conditions.

Plan conditionsCoverage requires physician/facility confirmation, contracted facility participation, written member consent acknowledging limited evidence, demonstrated physician/facility experience, and adherence to FDA labeling.

inv-119: Non-urgent ambulance/air transport — definition/context

DefinitionNon-urgent ambulance/air transport: non-emergency air or ambulance transportation between specified locations; prior authorization is required.

Representative codesExamples include HCPCS A0430, A0431, A0435, A0436 and S9960/S9961 per the document.

inv-120: SOS — SOS Only Applies term reference

TermSOS Only Applies: indicates the Site-of-Service (SOS) rules are applicable for the listed procedures; many entries are designated 'Outpatient' and SOS guidance affects PA requirements.

EffectWhen SOS applies the prior authorization requirement may depend on whether the service is performed in an outpatient hospital, office, or participating ASC, with exceptions noted by state.

inv-121: PSF — Patient Summary Form definition and timing

DefinitionPSF = Patient Summary Form: form that must be completed and submitted after the initial PT/OT visit by Optum-contracted providers.

TimingPSFs should be sent within three days of initiating treatment and must be received within 10 days from the initial date of service.

inv-122: Prosthetic PA threshold — prosthetic items PA threshold definition

ThresholdProsthetic items require prior authorization only when retail purchase or cumulative rental cost exceeds $1,000.

ExamplesDocument lists prosthetic HCPCS codes (e.g., L5010, L5050, L5060, L5100) subject to the $1,000 PA threshold.

inv-123: UnitedHealthcare Provider Portal Prior Authorization and Notification tool — portal/tool definition

Tool nameUnitedHealthcare Provider Portal Prior Authorization and Notification tool (PA & Notification app).

UseProviders use this portal/app to submit advance prior authorization requests for the procedures and services listed in the document.

Access stepsGo to UHCprovider.com, click the UnitedHealthcare Provider Portal button, then select the Prior Authorization and Notification app tile on the dashboard.

inv-124: Site of service (SOS) — definition and rule summary for SOS

DefinitionSite of service (SOS): the location where a procedure is performed; SOS rules describe when prior authorization is required (e.g., outpatient hospital) and when it may not be required (e.g., office or participating ASC in specified states).

Primary designationMany procedures in this document are designated SOS - Outpatient; the SOS designation affects PA handling and exceptions are noted by state.

Provider responsibilityCare providers ordering advanced outpatient imaging or other SOS-listed procedures are responsible for requesting prior authorization/notification before scheduling.

inv-125: Site of service (SOS) - Outpatient — repeated designation meaning

MeaningSite of service (SOS) - Outpatient indicates the procedure is performed in an outpatient setting (outpatient hospital) and is the primary SOS designation used across many listed procedures.

RelevanceThis SOS designation is repeatedly applied to colonoscopy screening and numerous other CPT/HCPCS entries in the policy.

PA implicationWhen SOS - Outpatient applies, prior authorization rules in the document govern whether PA is required or if exceptions (ASC/office) exist.

inv-126: Site of service location designation — repeated 'Outpatient' designation for procedure location

DefinitionSite of service location designation: 'Outpatient' — the document repeatedly designates the location where procedures are performed as Outpatient for the listed CPT/HCPCS codes.

ExamplesScreening colonoscopy and many ENT, GI, radiology and other procedural codes are marked with SOS = Outpatient in the policy excerpts.