CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Lists prior authorization requirements and submission methods for participating Preferred Care Network and Preferred Care Partners of Florida providers, covering inpatient and outpatient services for specified plans and groups.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone to the listed network contacts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-09-01Effective

2Phone contacts

Portal & phoneWellMed option

RequiredAdvance notification

Many servicesPrior auth required

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Optum 888-936-7246Transplant contact

Services Requiring Prior Authorization or Advance Notification

Prior authorization coverage criteria (section excerpt)

Covered when the specified service category and listed codes or circumstances apply; prior authorization is required as noted below.

Behavioral health services: many plans restrict coverage to a designated vendor; for specific codes requiring prior authorization, call the number on the member's health plan ID card.

ALL of the following

Relevant CPT/HCPCS codes: 20974, 20975, 20979.

Breast reconstruction (non-mastectomy): prior authorization required for listed procedures; associated diagnostic ICD-10 codes (e.g., C50.*, D05.*, Z85.3, Z90.1x) are referenced in the policy.

ALL of the following

Examples of J/Q codes called out: J1442, J1447, Q5108, Q5110, Q5111, Q5122, J0897, J2506.

Cardiology/vascular services: various cardiovascular procedures and codes are listed; some cardiology services are noted as no longer requiring prior authorization while others still require it (examples: select 37xxx series and code 93653).

Prior auth / notification criteria sets (excerpt)

Service categories shown below require either prior authorization or advance notification as specified.

ALL of the following

Scope: chemotherapy injectable drugs billed J9000-J9999, leucovorin J0640, levoleucovorin J0641–J0642, Q-coded chemotherapy, or miscellaneous HCPCS when no specific code assigned.

ALL of the following

Advance notification includes outpatient dialysis services and is required when referring to out-of-network dialysis providers; advance notification not required when a Medicare member travels outside the service area.

ALL of the following

Notification or prior authorization is required for specified CPT codes when submitted with diagnosis codes F64.x or Z87.890.

Prior authorization codes (partial)

Selected procedure codes excerpted from the policy that require prior authorization (several entries marked inpatient-only).

Prior authorization required for the following listed procedure codes (examples shown): 58267, 58270, 58290, 58291, 58292, 58294. Several of these are designated 'Inpatient only' in the policy text.

Dialysis services coding and prior authorization notes

Dialysis/ESRD services entries contain repeated code references and indicate prior authorization/advance notification requirements; explicit clinical criteria are not provided in this excerpt.

Advance notification or prior authorization is indicated for dialysis services/ESRD entries; providers should follow the policy's advance notification requirement for outpatient dialysis and for out-of-network referrals.

Repeated CPT/HCPCS code mentions in the dialysis section include 58292 and 58294 (appear multiple times in the dialysis entries); context for each appearance is not explicit in these chunks.

Operational note: the dialysis section refers to 'how to obtain prior authorization' in multiple lines but does not include procedural details in this excerpt — providers should use the plan's Prior Authorization and Notification tool or contact numbers listed elsewhere in the policy.

Prior authorization requirements — partial

Partial listing of prior authorization requirements and flagged items from the policy.

Prior authorization required: numerous entries across the document are explicitly marked 'Prior authorization required' (see injectable medications, dialysis entries, non-emergency air transport, inpatient/post-acute admissions, and multiple procedures).

Selected specialty drugs and injectable agents are identified as prior authorization required (see J-code lists in the injectable medications section).

Operational note: the dialysis/service entries include repeated placeholders and code repetitions (notably 58294); cross-reference to the full policy is needed to determine specific clinical criteria or exceptions.

Authorization-required items (excerpt)

Items and services in this excerpt are subject to the plan's prior authorization or notification process as listed.

ALL of the following

Examples from the list include: J0791 (Adakveo), J0172 (Aduhelm), J3111/J0897 (bone density agents), J1442/J1447 (colony-stimulating factors), J1411 (Hemgenix), J1306 (Leqvio), J1300 (Soliris), J1745 (Infliximab), J3032 (Vyepti), and many others referenced.

Hyaluronic acid polymers and immune globulin code mappings are shown (e.g., J7320/J7324/J7331 variants) — these mappings are used to determine quantity/code relationships for authorization purposes.

Therapeutic radiopharmaceuticals (e.g., A9513, A9590) and certain unclassified/temporary codes (e.g., J3490, J3590, C9172, C9399) are listed and require prior authorization or coordination per the policy.

Non-emergency air transport (specific A-codes) and prior authorization/notification for specified inpatient/post-acute facility admissions are explicitly required.

Prior authorization and coverage stance

The plan's overall coverage stance: many services require prior authorization or advance notification; out-of-network referrals and high-cost therapies follow specific authorization paths.

Prior authorization required for many listed procedures, therapies, drugs and device implantations (examples include non-emergency air transport, select orthopedic/spine surgeries, proton beam therapy, rhinoplasty/sleep apnea surgeries, transplant and cellular/gene therapies).

Out-of-network referrals: advance notification is required when a network provider directs a member to an out-of-network provider; prior authorization may be required to request in-network cost sharing or benefit level when no in-network providers are available.

Vendor-managed prior authorization: naviHealth manages prior authorization for in-scope membership; transplant and cellular/gene therapies require coordination through Optum Transplant Case Management (contact information provided in the policy).

Radiation therapy and potentially unproven ambulatory services: specific modalities (e.g., proton beam therapy, stereotactic radiosurgery) and ambulatory experimental/investigational services require prior authorization; insufficient clinical evidence may lead to non-coverage or the requirement for prior authorization.

Out-of-network prior authorization overview

Out-of-network services that require advance notification or prior authorization and the required coordination contacts.

Organ/tissue transplant and transplant-related services — prior authorization required; providers must contact Optum Transplant Case Management at 888-936-7246 or use the notification number on the member's health plan ID card for pre-treatment evaluation and authorization coordination.

Cellular and gene therapies (listed CAR‑T and gene therapies) — prior authorization and pre-treatment evaluation required; contact Optum Transplant Case Management at 888-936-7246 or follow the notification instructions on the member ID.

Ventricular assist devices (VAD) — prior authorization required for VADs; providers should call the Optum VAD Case Management team at 888-936-7246 or the notification number on the member's health plan ID card.

Operational note: when directing care to out-of-network providers, advance notification is required and members may have increased out-of-pocket costs or no coverage; prior authorization pathways described above apply.

Relevant CPT / HCPCS / ICD-10 / Drug Codes

Selected CPT/HCPCS/NDC examples referencedmixedCovered

20974	Bone growth stimulator (CPT/HCPCS referenced)
20975	Bone growth stimulator (CPT/HCPCS referenced)
20979	Bone growth stimulator (CPT/HCPCS referenced)
19316	Breast reconstruction — non-mastectomy
19318	Breast reconstruction — non-mastectomy
19325	Breast reconstruction — non-mastectomy
L8600	Breast prosthesis/device (HCPCS)
J1442	Colony-stimulating factor (example listed)
J1447	Colony-stimulating factor (example listed)
Q5108	Colony-stimulating factor (example listed)

1–10 of 20

1/2

Selected CPT/HCPCS/NDC examples referenced (duplicate J1447 entry)mixedCovered

J1447

Tbo-filgrastim (Granix) (also listed above)

ICD-10 diagnosis codes tied to prior authorization or notification rulesICD-10

C50.*	Multiple ICD-10 codes for breast cancer diagnoses listed (e.g., C50.011, C50.012, etc.)
Z85.3	Personal history of malignant neoplasm of breast
Z90.10	Acquired absence of breast
I70.*	Multiple peripheral vascular disease ICD-10 codes referenced

Listed ICD-10 groupsICD-10

I70.*	Multiple peripheral vascular / arterial ICD-10 codes listed (I70.343 - I70.763 etc.)
M86.*	Multiple osteomyelitis ICD-10 codes listed (M86.05x, M86.15x, M86.2xx, M86.3xx, etc.)
Various S/T/T82 etc.	Trauma/device-related ICD-10 codes listed (S81., S91., T82.*, etc.)

Listed CPT/HCPCS groupsmixed

J9000-J9999, J0640-J0642	Injectable chemotherapy HCPCS codes and leucovorin/levoleucovorin codes requiring notification
Selected CPT codes (examples)	Examples shown for cochlear implants, hysterectomy, gender dysphoria-related procedures and others (e.g., 27415, 27416, 69714, 69930, 11960, many 5xx/6xx codes)

Procedure codes requiring prior authorization (excerpt)CPT | HCPCSCovered

58267	Hysterectomy (vaginal) — referenced for prior authorization
58270	CPT/HCPCS referenced (inpatient-only)
58290	CPT/HCPCS referenced (inpatient-only)
58291	CPT/HCPCS referenced (inpatient-only)
58292	CPT/HCPCS referenced (appears repeatedly; inpatient-only)
58294	CPT/HCPCS referenced

Dialysis-related CPT/HCPCS codes mentionedCPT | HCPCS

58292	Code referenced repeatedly in dialysis services section (context unclear)
58294	Code referenced repeatedly in dialysis services section (context unclear)

Dialysis-related code mentionsmixed

58294

Repeatedly listed in dialysis services entries; exact coding system not explicitly labeled in this window

Prior authorization J-codesHCPCSCovered

J0791	Adakveo
J0172	Aduhelm
J7171	Adzynma
J0225	Amvuttra
J2786	Ashthma**
J2182	Ashthma**
J0585	Botulinim toxins
J0586	Botulinim toxins
J0587	Botulinim toxins
J0588	Botulinim toxins

1–10 of 14

1/2

Selected injectable HCPCS J-codes listedHCPCS | mixed

J3111	Bone density agent
J0897	Bone density agent
J2329	Briumvi
J1442	Colony-stimulating factor
J1447	Colony-stimulating factor
J1411	Hemgenix
J1306	Leqvio
J1300	Soliris
J1745	Infliximab
J3032	Vyepti

Therapeutic radiopharmaceuticals and other A-codesCPT | mixed

A9513	Therapeutic radiopharmaceutical
A9590	Therapeutic radiopharmaceutical

Selected J-codes and specialty drugs referencedHCPCSCovered

J0177	Vascular endothelial growth factor (VEGF) inhibitors listed
J3032	Vyepti (listed among HCPCS/J-codes)
J9332	Vyvgart
J3399	Zolgensma (listed)

Procedure and therapy CPT ranges shownCPTCovered

77520-77525	Proton beam therapy / focused radiation therapy codes referenced
62350-62362	Pain management injection procedure codes
30400-30462	Rhinoplasty codes
41812	Example sleep apnea/procedure codes (multiple specific codes listed)

Device implant codesHCPCSCovered

L8682-L8683

Implantable device/lead codes (neurostimulator related)

Transplant, cellular/gene therapy, and VAD codesmixed

38240	Bone marrow harvest
33940	Heart transplant code (example listed)
32850	Lung transplant related code (example listed)
0537T	Cellular and gene therapy procedure code (example listed)
0538T	Cellular and gene therapy procedure code
0539T	Cellular and gene therapy procedure code
0540T	Cellular and gene therapy procedure code
C9399	Unclassified code (examples: Casgevy, Lantidra, Lenmeldy referenced)
J3490	Unclassified drug code
J3590	Unclassified drug code

1–10 of 16

1/2

Hyaluronic acid polymer quantity mapping

Mapping overviewJ7320 and J7324 map to multiple quantity-specific codes (e.g., J7320 → J7321, J7322, J7323; J7324 → J7326, J7327, J7329).

Additional J7331 mappingJ7331 has quantity variants referenced (J7331 → J7332; further quantity mappings appear incomplete in source).

Immune globulin cross-referencesImmune globulins (IVIG, SCIG) are listed alongside quantity mappings and related code cross-references (e.g., 90283 → 90284; J1552 → J1554/J1555/J1556).

Actionable note

How to Submit Requests, Contacts, and Notification Requirements

Prior Authorization

Online prior authorization submission

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal by signing in with a One Healthcare ID and selecting the Prior Authorization and Notification tab on the dashboard.

Prior Authorization

Phone prior authorization submission

Call the plan-specific phone numbers to request prior authorization: Preferred Care Network: 866-273-9444; Preferred Care Partners: 800-995-0480.

Prior Authorization

WellMed submission option

For designated WellMed groups, submit prior authorization requests via the WellMed provider portal at eprg.wellmed.net or by calling 877-299-7213, 8 a.m. to 5 p.m. ET, Monday–Friday.

Applicable groups include MedicareMax (HMO) groups 98151, 98152; MedicareMax Chronic (HMO C-SNP) group 90215; MedicareMax Plus (HMO D-SNP) groups 98153–98155.

Terms and Mappings

Prior authorization

DefinitionPrior authorization: Authorization obtained in advance for certain services or medications; not required for emergency or urgent care and may be required in addition to referrals for some plans.

Primary submission methodSubmit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) via One Healthcare ID.

Phone contactsPhone submission options: Preferred Care Network: 866-273-9444; Preferred Care Partners: 800-995-0480.

ExceptionsSome services are excluded from prior authorization requirements for specific plans — check the member's plan and ID card for referral/prior auth rules.

WellMed portal

WellMed submission portalFor specified WellMed groups, submit prior authorization requests via the WellMed provider portal at eprg.wellmed.net.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone to the listed network contacts.

SourceLink

On This Page

Cochlear implants and other auditory implants — prior authorization required.

Examples of procedure groups

Selected CPT examples listed near this section (e.g., 27415, 69714, 69930) — follow prior authorization or notification rules above.
Cosmetic and reconstructive procedures: prior authorization required as listed.

When billing hyaluronic acid polymers, select the specific J-code variant that corresponds to the billed quantity per the J7320/J7324/J7331 mappings to avoid authorization denials.

38232 prior authorization condition

ContextThis conditional requirement appears in the out-of-network services section and is repeated multiple times, indicating a limited/exception-based prior authorization trigger.

Provider actionConfirm the specific triggering condition (e.g., service context or setting) before submitting a prior authorization for 38232 to determine if authorization is required.

Note

Emergency / referral note

Prior authorization is not required for emergency or urgent care; providers should note that some plans list 'Referral Required' on the member ID card and those services may also require a referral and prior authorization.

Prior Authorization

How to obtain prior authorization / notification

Submit prior authorization and notification requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by calling 888-397-8129 as indicated in the document.

Note

Advance notification / Notification requirements

Advance notification is required for specified inpatient or outpatient services, including dialysis/ESRD services and when referring to out-of-network dialysis providers; notification is also required for outpatient injectable chemotherapy drugs.

ESRD/dialysis services require advance notification; not required for Medicare members traveling outside the service area (chunk 32).
Injectable chemotherapy drugs administered in outpatient settings require notification (chunk 28).

Prior Authorization

Prior authorization required for specific service categories

Prior authorization is required for the listed service categories such as cochlear implants, certain chemotherapy services, gender dysphoria treatment, and various cosmetic/reconstructive procedures as shown in the document.

Cochlear and other auditory implants require prior authorization (chunk 27).
Gender dysphoria treatment procedures require prior authorization or notification as specified (chunk 32).

Documentation Required

DME vendor routing

All requests for durable medical equipment must be directed to a health plan contracted vendor; call the number on the member's health plan ID card for details.

Prior Authorization

Prior authorization — listed procedure codes

The document lists specific CPT/HCPCS procedure codes that require prior authorization (examples include 58267, 58270, 58290, 58291, 58292, 58294); several entries are marked inpatient-only and additional information references hysterectomies.

Example procedure codes requiring prior authorization: 58267, 58270, 58290, 58291, 58292, 58294.

Prior Authorization

Dialysis services prior authorization codes

Dialysis services entries reference CPT/HCPCS codes and indicate that prior authorization/advance notification is required for ESRD-related services; the section repeatedly references codes 58292 and 58294 in the dialysis context.

Advance notification required for outpatient dialysis/ESRD services (chunk 32).
Repeated code mentions in the dialysis section include 58292 and 58294 (chunk 54).

Prior Authorization

Dialysis services — prior authorization placeholders and repeated code

The dialysis section contains repeated placeholders for CPT/HCPCS prior authorization instructions and repeatedly lists code 58294 across multiple entries; providers should follow the advance notification/prior authorization instructions in the portal or by calling the plan contacts.

Code 58294 appears multiple times in the dialysis entries (chunks 74–76).
Operational submission should use the Portal or phone contacts as described elsewhere in the document (see chunks 1 and 28).

Prior Authorization

Selected J-code drug prior authorization list

The document identifies a list of injectable drugs by HCPCS J-code that are marked 'Prior authorization required*' (examples include J0791 Adakveo, J0172 Aduhelm, J7171 Adzynma, J0225 Amvuttra, J3111, J0897, J2329).

Examples of J‑codes listed as prior authorization required include J0791, J0172, J7171, J0225, J3111, J0897, J2329.

Prior Authorization

Inpatient/post-acute admission prior authorization and notification

Prior authorization and notification of admission date are required for post‑acute inpatient services including acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals, and skilled nursing facilities (with specified plan exclusions for SNF prior authorization).

Note lists exclusions from the SNF prior authorization requirement: UnitedHealthcare Assisted Living Plans (HMO‑SNP, HMO‑POS SNP, PPOSNP) and UnitedHealthcare Nursing Home plan (chunk 107).

Prior Authorization

Non-emergency air transport prior authorization

Non‑emergency air transport (non‑urgent ambulance by air) requires prior authorization; example HCPCS/A‑codes referenced include A0430, A0431, A0435, and A0436.

Non‑emergency air transport codes listed: A0430, A0431, A0435, A0436 (chunk 108).

Prior Authorization

Prior authorization for injectable medications (HCPCS J-codes)

Numerous injectable medications billed with HCPCS J‑codes require prior authorization; the document provides examples of J‑codes and instructs providers to use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or the listed phone contacts to obtain authorization.

Examples of J‑codes referenced include J0177, J3032, J9332, J3399 and others throughout the J‑code lists (chunk 109).
For submission use the Portal (uhcprovider.com) or call 888‑397‑8129 as noted in the document (chunk 109).

Prior Authorization

How to obtain prior authorization / vendor contacts

To submit prior authorizations and for vendor-managed authorizations: use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (uhcprovider.com) or call 888-397-8129; naviHealth manages prior authorization for in‑scope membership (Phone: 855-851-1127; Fax: 844-244-9482).

naviHealth contact for in‑scope membership: Phone 855‑851‑1127; Fax 844‑244‑9482 (chunk 109).

Prior Authorization

Transplant and cellular/gene therapy prior authorization contact

For transplant and cellular/gene therapy services and pre‑treatment evaluations, providers must call the Optum Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's health plan ID to obtain prior authorization.

This includes CAR‑T and specified gene therapies listed in the document (chunk 127).

Prior Authorization

Out-of-network advance notification / prior authorization

Advance notification and/or prior authorization are required for certain out‑of‑network referrals and specified out‑of‑network procedures (for example, Preferred Care Vein procedures and some pain management services); providers should obtain advance notification when directing members to out‑of‑network providers.

Advance notification required for Preferred Care Vein procedures; prior authorization required for some out‑of‑network pain management referrals (chunk 118–119).

Prior Authorization

Transplant and cellular/gene therapy prior authorization contact

For cellular and gene therapies and transplant‑related services, providers should call the Optum Transplant Case Management team at 888-936-7246 or use the notification number on the member ID to obtain prior authorization or notification.

Prior Authorization

VAD prior authorization contact

For ventricular assist devices (VAD), providers must call the Optum VAD Case Management team at 888-936-7246 or the notification number on the back of the member's health plan ID card to obtain prior authorization.

Example VAD procedure codes referenced include 33975, 33976, 33979, 33981, 33982 (chunk 134).

WellMed phone optionWellMed phone contact: 877-299-7213, 8 a.m.–5 p.m. ET, Monday–Friday.

Applicable groupsApplies to WellMed groups including MedicareMax (HMO) groups 98151/98152, MedicareMax Chronic (HMO C-SNP) group 90215, and MedicareMax Plus (HMO D-SNP) groups 98153/98154/98155.

Advance notification

DefinitionAdvance notification: Providers must notify the plan in advance for certain inpatient or outpatient services; specifically required for dialysis/ESRD services and when referring to out-of-network dialysis providers.

Where requiredAdvance notification is required for outpatient dialysis services and when referring members to out-of-network dialysis centers to help avoid high out-of-pocket costs.

How to notifyUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or follow plan-specific notification contact instructions on the member ID card.

Notification (chemotherapy injectable drugs)

ScopeNotification required for injectable chemotherapy drugs administered in outpatient settings (J9000–J9999, J0640–J0642, Q-codes, or miscellaneous HCPCS).

Submission instructionsSubmit notifications via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the portal phone contact as referenced in the document.

Related servicesAdvance notification also applies to certain dialysis and outpatient services as noted elsewhere in the policy.

inpatient-only

TermInpatient-only: Several listed CPT/HCPCS hysterectomy and related procedure codes are marked 'Inpatient only' in the dialysis/services section (examples: 58267, 58270, 58290–58292, 58294).

ImplicationIf a procedure is designated inpatient-only, prior authorization and appropriate inpatient admission notification processes apply; verify setting before submission.

Provider checkConfirm the service setting (inpatient vs. outpatient/vaginal) as some hysterectomy-related codes have different authorization expectations.

hysterectomies

ContextHysterectomies are referenced as additional information for multiple listed codes; examples include vaginal and inpatient hysterectomy CPT codes (e.g., 58267, 58270, 58290–58294).

Authorization noteMany hysterectomy-related codes in the list require prior authorization; inpatient-only designations are noted for several codes.

ActionWhen scheduling or billing hysterectomy procedures, confirm the exact CPT code and setting to determine prior authorization needs.

how to obtain prior authorization

Online submission (recommended)Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and select the Prior Authorization and Notification tab.

Phone optionsCall 888-397-8129 for portal/phone prior authorization support as referenced for some services; use plan-specific numbers (866-273-9444 or 800-995-0480) for PCN/PCP groups.

Vendor-managed workflowsnaviHealth manages prior authorization for in-scope membership (Phone: 855-851-1127; Fax: 844-244-9482) — follow vendor instructions where applicable.

Prior authorization

DefinitionPrior authorization: Advance approval process required for many listed procedures, services and drugs; exceptions include emergency/urgent care.

Portal instructionUse the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) to submit requests; One Healthcare ID required.

Alternate contactsUse phone numbers provided for specific networks or services (PCN: 866-273-9444; PCP: 800-995-0480) and specialty/vendor contacts listed in the policy (e.g., naviHealth).

Hyaluronic acid polymers / Immune globulins (IVIG, SCIG)

Hyaluronic acid polymers mappingHyaluronic acid polymer codes include J7320 and J7324 with multiple quantity-specific mappings (see J7320→J7321/J7322/J7323 and J7324→J7326/J7327/J7329); J7331 has at least one mapped variant (J7332).

Immune globulin referencesImmune globulins (IVIG, SCIG) are listed alongside mapping entries and associated code cross-references (e.g., 90283→90284; J1552→J1554/J1555/J1556), indicating related authorization/coding relationships.

Operational noteUse the precise mapped J-code corresponding to the administered quantity when requesting prior authorization to ensure correct processing.

Prior authorization / Notification

Notification vs prior authorizationInjectable chemotherapy drugs (J9000–J9999 and certain Q-codes) require notification; many injectable medications (J-codes) across the document require prior authorization.

Submission pathUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit either notifications or prior authorization requests as specified.

Check specific drug entriesRefer to the listed J-code entries in the policy (e.g., J1442, J1447, J3111, J2329) to determine if a specific injectable requires notification only or full prior authorization.

Out-of-network services

Out-of-network referralsAdvance notification and/or prior authorization may be required when directing a member to an out-of-network provider; members may face increased out-of-pocket costs or no coverage.

When requiredExamples include Preferred Care Vein procedures, pain management referrals, transplant and specialized therapies when no in-network providers are available.

Provider instructionContact the notification number on the member's health plan ID or follow plan instructions to request prior authorization or in-network cost-sharing consideration.

Transplant prior authorization contact

Transplant contactFor transplant and cellular/gene therapy services, contact the Optum Transplant Case Management team at 888-936-7246 or use the notification number on the member's health plan ID.

ScopeThis contact is required for pre-treatment evaluation and authorization coordination for listed CAR-T and other cellular/gene therapies (e.g., tisagenlecleucel, Yescarta, Zynteglo, etc.).

RepetitionThe policy repeats this Optum contact instruction multiple times in the transplant/cellular therapy section, indicating mandatory coordination for these services.

Ventricular assist devices (VAD)

VAD contactFor ventricular assist devices (VAD), providers must call the Optum VAD Case Management team at 888-936-7246 or the notification number on the back of the member's health plan ID to obtain prior authorization.

Codes referencedVAD-related CPT codes cited include 33975, 33976, 33979, 33981 and 33982; prior authorization routing via Optum VAD Case Management is required.

DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow; prior authorization required.