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 instructions for participating Preferred Care Network and Preferred Care Partners of Florida providers, including plan groups and specific services/drugs that require prior authorization. Affects in-network providers serving members of the listed Medicare and regional plans.

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, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by the listed phone numbers; emergency and urgent care are exempt.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

uhcprovider.comportal

WellMed portalWellMed route

Part BStep Therapy

severalDevice codes

multiple

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Notification required

Services and Codes Requiring Prior Authorization / Notification

Prior authorization / notification requirements (excerpt)

Notification or prior authorization requirements (excerpt). Consolidated guidance from the source: certain devices, implants, and selected procedures require prior authorization or notification. Submit requests using the payer portal or call the number on the member ID card as indicated.

Notification or prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) — includes chemotherapy injectable drugs (J9000–J9999), Leucovorin (J0640), Levoleucovorin (J0641, J0642), chemotherapy drugs with a Q-code, and drugs billed under miscellaneous HCPCS (unassigned codes). For prior authorization, submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) and select the Prior Authorization and Notification tab.

Continuous glucose monitors (A4238, A4239, E2102, E2103) — notification required. Submit notification or prior authorization via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com).

Cochlear implants and other auditory implants — notification required. Follow portal submission instructions for prior authorization/notification.

Cartilage implants (CPT 27415, 27416) — prior authorization required.

Gender dysphoria treatment procedures — notification or prior authorization required depending on code and diagnosis. Specific CPT codes require notification or prior authorization when billed with diagnosis codes F64.0, F64.1, F64.2, F64.8, F64.9 or Z87.890 (examples include 14000, 14001, 14041, 15734, 15738, 15750, 15757, 15758, 15775, 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, 54400, 54405, 54408, 54520, 54660, 54690, 55175, 55180).

Non-emergency air transport (A0430, A0431, A0436) — prior authorization required for non-urgent ambulance transportation by air.

Device-related diagnosis codes and certain vascular/implant codes (example ICD-10: T82.319A, T82.338A, T82.392A, T82.398A, T82.399A, T82.898A; peripheral vascular: I73.00, I73.01, I73.1, I73.81) — check payer requirements; prior authorization or notification may be required.

General submission guidance: use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool at UHCprovider.com to submit prior authorization or notifications. When portal use is not available follow the phone/fax instructions on the member's ID card or the payer communications (call center number listed on the ID card).

CPT / HCPCS / ICD-10 Code Examples and Groups

Breast reconstruction - Non-mastectomy (Sample CPT)CPT

19316	Mastectomy, reconstruction with prosthesis, immediate or delayed
19318	Mastectomy, immediate reconstruction with tissue expander/implant
19325	Breast augmentation, augmentation mammoplasty (included for reconstructive/cosmetic grouping)

Antiemetic and Supportive Care HCPCS/J-codesHCPCS

J1454	Palonosetron and fosnetupitant (Akynzeo)
J1456	Palonosetron (other antiemetic)
J1442	Aprepitant, injectable formulation
J1447	Tbo-filgrastim (Granix) - colony stimulating factor
Q5108	Pegfilgrastim-jmdb (Fulphila) Q-code
Q5110	Filgrastim biosimilar Q-code (example)
Q5111	Filgrastim biosimilar Q-code (example)
Q5122	Pegfilgrastim-apgf (Nyvepria) Q-code

Selected Colony-Stimulating Factors and Related HCPCS/J-codesHCPCS

J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria) Q-code
Q5101	Filgrastim-sndz (Zarxio) Q-code
J2820	Sargramostim (Leukine)
J1447	Tbo-filgrastim (Granix)
J1448	Trilaciclib (Cosela)
J0897	Denosumab (Xgeva/Prolia) - bone-modifying agent

Additional Injectable HCPCS/J-codesHCPCS

J0177

Injection, aflibercept (example injectable retinal agent)

How to Submit Prior Authorizations, Notifications, and Special Instructions

Prior Authorization

Submit authorizations via UHC Provider Portal or phone; emergency/urgent care exempt

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone: Preferred Care Network 866-273-9444; Preferred Care Partners 800-995-0480. Prior authorization is not required for emergency or urgent care.

Prior Authorization

WellMed groups: use WellMed portal or phone

For the specified WellMed groups, submit prior authorization requests on the WellMed provider portal (eprg.wellmed.net) or by calling 877-299-7213, 8 a.m.–5 p.m. ET, Monday–Friday.

Groups: MedicareMax (HMO) 98151, 98152; MedicareMax Chronic (HMO C-SNP) 90215; MedicareMax Plus (HMO D-SNP) 98153, 98154, 98155.

Prior Authorization

Check member ID for referral requirement

Key Terms and Portal / Program Definitions

Prior authorization

DefinitionPrior authorization is the process by which providers must obtain approval from the health plan before delivering certain services or drugs; emergency and urgent care are exempt.

ScopeApplies to participating Preferred Care Network and Preferred Care Partners of Florida for listed inpatient and outpatient services.

When not requiredPrior authorization is not required for emergency or urgent care.

Notification required

MeaningNotification required indicates providers must submit a notification via specified channels (often for listed injectable chemotherapy drugs and some procedures).

ExamplesInjectable chemotherapy administered outpatient (J9000–J9999, J0640–J0642, Q‑codes) are listed as requiring notification.

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, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by the listed phone numbers; emergency and urgent care are exempt.

SourceLink

On This Page

If a member’s ID card indicates 'Referral Required', certain services may also require a PCP referral and prior authorization obtained by the treating physician.

Prior Authorization

Cartilage implants require prior authorization

Cartilage implant procedures (CPT 27415, 27416) require prior authorization.

Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Documentation Required

Cochlear and auditory implants — notification / PA via portal

Cochlear and other auditory implants require notification; some implant items reference prior authorization—submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Examples of device codes listed: 69714, 69930, L8614, L8619, L8690–L8692.

Prior Authorization

Continuous glucose monitors require prior authorization

Continuous glucose monitor devices (A4238, A4239, E2102, E2103) require prior authorization; submission is via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Documentation Required

Outpatient injectable chemotherapy — notification via portal

Injectable chemotherapy drugs administered in outpatient settings require notification; providers should submit requests and notifications through the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Includes J9000–J9999, Leucovorin (J0640) and Levoleucovorin (J0641, J0642), Q-code chemotherapy drugs, and miscellaneous HCPCS-billed agents.

Prior Authorization

Osteomyelitis (M86*) codes require prior authorization

Multiple osteomyelitis diagnosis codes (M86.*) are listed with 'how to obtain prior authorization' indicated—treating providers must obtain prior authorization for services tied to these codes.

Examples include M86.351, M86.352, M86.359, M86.461–M86.479, M86.551–M86.572 and related M86.* codes.

Prior Authorization

Injectable chemotherapy — portal submission for notification/PA

Injectable chemotherapy agents billed in outpatient settings require notification and, where indicated, prior authorization; submit via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Relevant drug ranges include J9000–J9999, J0640–J0642 and Q-code agents.

Prior Authorization

ESRD/dialysis services require advance notification

Advance notification is required for inpatient or outpatient ESRD/dialysis services and when referring members to out-of-network dialysis providers; contact the number on the member’s ID card for details.

All durable medical equipment requests should be directed to a health plan contracted vendor.

Prior Authorization

Gender dysphoria treatments require prior authorization/notification

Gender dysphoria treatments and specified CPT/HCPCS codes require prior authorization or notification as listed; providers must submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Some codes require authorization regardless of diagnosis; other codes require authorization when billed with F64.x or Z87.890. Examples and long code lists are provided in the policy.

Billing Rule

Medication codes (e.g., J1302) noted for authorization/billing

Medication coding entries in the gender dysphoria section repeatedly reference HCPCS J1302 (Enjaymo) and other J-codes; these entries indicate billing codes that require prior authorization or special handling.

J1302 appears frequently in the medication list for gender dysphoria–related entries.

Prior Authorization

How to obtain prior authorization — portal, phone, fax

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). After sign-in, select the Prior Authorization link to create a new authorization; phone: 855-851-1127; fax: 844-244-9482.

Prior Authorization

Inpatient admissions — notification and PA for listed inpatient drugs

Inpatient admissions require notification; prior authorization is referenced for listed inpatient drugs (examples: Vyvgart J9332, Vyvgart Hytrulo J9334, Zolgensma J3399) — submit via the UnitedHealthcare Provider Portal.

Submit inpatient drug authorization/notification via Prior Authorization and Notification on UHCprovider.com.

Prior Authorization

Non-emergency air transport requires prior authorization

Non-emergency (non-urgent) air transport (A0430–A0436) requires prior authorization; submit requests through the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Prior Authorization

Prior authorization submission: use UHCprovider Prior Authorization and Notification

When submitting prior authorization requests, sign in to UHCprovider.com, select the Prior Authorization and Notification tab, then create a new authorization via the Prior Authorization link.

Step Therapy

Part B Step Therapy applies to some listed drugs

Some drugs listed in this policy are included in the Part B Step Therapy Program; providers should account for step therapy program requirements when requesting authorization.

Prior Authorization

Portal instructions for prior authorization

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (sign in at UHCprovider.com and create a new authorization).

Step Therapy

Part B Step Therapy program inclusion and notification

The Part B Step Therapy Program is noted for multiple services/drugs in this section; notification is required for some procedures—follow portal instructions to notify or request authorization.

Prior Authorization

Portal workflow: sign in → Prior Authorization → Create a new authorization

Sign in to UHCprovider.com, select the Prior Authorization link and create a new authorization to submit requests for the listed services and drugs (portal submission emphasized throughout the policy).

Documentation Required

Follow portal process when 'Notification required' is indicated

Several entries in the document note 'Notification required' for specific items; when shown, follow the Prior Authorization and Notification process on UHCprovider.com to submit the required notification.

Prior Authorization

Submit prior authorization via UHCP provider portal (portal required)

Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) to submit authorizations for the listed J-codes and other items; after sign-in select Prior Authorization and create a new authorization.

Examples cited in the policy include J9332, J9334, J3399.

Documentation Required

Notification required — submit via portal

The document repeatedly indicates 'Notification required' for several items; when present, providers must submit the notification via the Prior Authorization and Notification tool on UHCprovider.com.

Prior Authorization

How to obtain prior authorization via UHCprovider.com

To obtain prior authorization for the listed drugs and services, sign in to UHCprovider.com, select the Prior Authorization link and Create a new authorization in the Prior Authorization and Notification tool.

Prior Authorization

Portal is primary submission method for prior authorization

Use UHCprovider.com Prior Authorization and Notification to submit prior authorization requests; the portal is the primary submission method emphasized across the policy.

Note

Notification vs prior authorization — follow portal instructions

Some sections note both notification and prior authorization requirements; when 'Notification required' is listed, follow the portal notification workflow; when prior authorization is listed, create a new authorization via the portal.

Prior Authorization

Submit prior authorization via UHC Provider Portal

Several blocks instruct providers to submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com); sign in and select Prior Authorization to create a new authorization.

Documentation Required

Ambiguous 'Notification required' entries — use portal notification

Certain sections list 'Notification required' language without additional operational details; when encountered, use the portal to submit the required notification as indicated by the policy.

Prior Authorization

Portal submission steps (partial): sign in → Prior Authorization → Create new authorization

Partial portal instructions appear across the policy: sign in at UHCprovider.com, select Prior Authorization, then Create a new authorization—use this portal workflow to submit requests.

Prior Authorization

Use UHC Provider Portal Prior Authorization and Notification tool

To submit prior authorization requests for the listed services and drugs, use the Prior Authorization and Notification tool on UHCprovider.com; the policy consistently references this portal for authorization submissions.

Prior Authorization

Portal workflow reiterated for obtaining prior authorization

Follow the portal instructions at UHCprovider.com to obtain prior authorization for referenced items; the policy repeatedly directs providers to sign in, select Prior Authorization, and create a new authorization.

Step Therapy

Notification and Part B Step Therapy — follow program and portal rules

Notification and Part B Step Therapy program notes appear together for many drugs; when a drug is noted as included in the Part B Step Therapy Program, providers should follow step therapy requirements and submit authorizations/notifications via the portal.

Prior Authorization

Submit prior authorization via provider portal

Submitting prior authorization is performed via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool—sign in at UHCprovider.com and use the Prior Authorization function to create requests.

Step Therapy

Part B Step Therapy Program applicability (multiple drugs)

The Part B Step Therapy Program is applicable to multiple drugs listed in this policy; when a drug is included, providers must adhere to step therapy sequencing as part of the authorization process.

ActionFollow the UnitedHealthcare Provider Portal Prior Authorization and Notification workflow to submit notifications.

Prior authorization required

RequirementPrior authorization required for services and devices listed (examples: cartilage implants 27415, 27416; continuous glucose monitor supplies A4238/A4239).

ExamplesCartilage implants (27415, 27416); continuous glucose monitors (A4238, A4239); many HCPCS/J‑codes for Part B drugs (e.g., J9332, J9334, J3399).

Scope noteSome items may require authorization regardless of diagnosis; others only when submitted with specified diagnosis codes (see code lists).

Provider submission method

Primary methodOnline via the UnitedHealthcare Provider Portal using the Prior Authorization and Notification tool (UHCprovider.com).

PhonePreferred Care Network: 866‑273‑9444; Preferred Care Partners: 800‑995‑0480; supplemental phone listed for inpatient portal (855‑851‑1127).

FaxFax submissions referenced: 844‑244‑9482 (where applicable per portal guidance).

Advance notification (ESRD)

Advance notification requiredAdvance notification is required for inpatient or outpatient ESRD/dialysis services and when referring members to out‑of‑network dialysis providers.

DME requestsAll requests for durable medical equipment should be directed to a health plan contracted vendor.

Member contactFor more information, call the number on the member's health plan ID card.

Enjaymo

Drug referencedEnjaymo is listed among medications in the gender dysphoria/medication sections (appears associated with HCPCS entries such as J1413 and J1302).

ContextEnjaymo appears repeatedly in the medication lists for gender dysphoria treatment entries in the document.

Coding noteDocument shows Enjaymo alongside HCPCS/J‑code entries but does not provide clinical criteria in the excerpt.

Prior authorization submission

Portal workflowUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal: sign in, select the Prior Authorization link, then 'Create a new authorization'.

Alternate contactsPhone: 855‑851‑1127; Fax: 844‑244‑9482 (as noted in portal guidance for certain submissions).

ScopeApplies to prior authorization requests for listed inpatient drugs and Part B medications (examples referenced throughout the document).

Non-emergency air transport

Service codesNon‑emergency air transport requires prior authorization for HCPCS codes A0430–A0436.

DefinitionNon‑urgent ambulance transportation by air is classified under A04xx HCPCS codes in this document.

How to submitSubmit prior authorization via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (uhcprovider.com).

Part B Step Therapy Program

ProgramPart B Step Therapy Program: several drugs listed in this document are noted as included in the Part B Step Therapy Program.

ImplicationInclusion in the program may require step therapy sequencing or additional documentation prior to approval.

Where referencedPart B Step Therapy mentions appear repeatedly alongside J‑codes and procedure entries throughout the drug lists.

UnitedHealthcare Provider Portal

Portal nameUnitedHealthcare Provider Portal — the web portal cited for submitting prior authorization requests via the Prior Authorization and Notification tool (UHCprovider.com).

AccessSign in with One Healthcare ID; instructions available at UHCprovider.com/access for creating an ID.

FunctionUse the Prior Authorization and Notification tab on the portal dashboard to create and manage authorizations and notifications.

UnitedHealthcare Provider Portal prior authorization tool

ToolPrior Authorization and Notification tool on the UnitedHealthcare Provider Portal — used to submit prior authorization requests; after sign‑in select Prior Authorization and 'Create a new authorization'.

ExamplesReferenced repeatedly for submitting authorizations for Part B drugs such as Vyvgart (J9332), Vyvgart Hytrulo (J9334), and Zolgensma (J3399).

Support contactsPhone support referenced in portal guidance (e.g., 855‑851‑1127) and fax where provided (844‑244‑9482).

A program noted as applying to certain drugs/services in this section

Program referencedPart B Step Therapy Program — a program noted as applying to certain drugs and services in drug lists and procedure entries.

OccurrencesDocument flags multiple drugs with 'also included in the Part B Step Therapy Program' annotations across the drug sections.

Provider actionWhen a drug is included in the program, follow step therapy requirements as part of the authorization process (portal submission).

Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal — primary method for submitting prior authorizations and notifications.

Portal stepsSign in at UHCprovider.com, select the Prior Authorization tab, then 'Create a new authorization' to submit requests.

Applies toUsed for notifications and prior authorizations for listed services, including inpatient admissions and Part B drugs.

Prior Authorization submission process

Submission processTo submit a prior authorization, sign in to the UnitedHealthcare Provider Portal, select Prior Authorization, then Create a new authorization; portal is the documented primary submission route.

Alternate routesPhone and fax numbers are provided in some sections (e.g., Phone: 855‑851‑1127; Fax: 844‑244‑9482) for select submissions.

NotesCertain plan groups (WellMed) may use different submission routes (see WellMed portal guidance).

Part B Step Therapy Program

Program namePart B Step Therapy Program — mentioned multiple times as applicable to listed drugs in the document.

EffectInclusion in the program may impose step therapy sequencing requirements before coverage is approved.

Reference patternThe document annotates many J‑codes and drug entries with 'also included in the Part B Step Therapy Program'.

Part B Step Therapy Program (mentioned as applicable to listed drugs)

Applies to listed drugsPart B Step Therapy Program — repeatedly referenced as applicable to drugs listed in multiple sections of the document.

Operational implicationProviders should expect step therapy rules to affect prior authorization determinations for included drugs.

Submission via portalEven for Step Therapy drugs, prior authorization submission is via the UnitedHealthcare Provider Portal tool as instructed.

Prior Authorization

DefinitionPrior Authorization: submission via the UnitedHealthcare Provider Portal — sign in, select Prior Authorization, and create a new authorization.

Use caseReferenced for inpatient admissions and Part B drug authorizations throughout the document.

SupportPhone and fax support details appear alongside portal instructions in several sections.

Part B Step Therapy Program

Program repeatedPart B Step Therapy Program — program mentioned repeatedly and associated with many Part B drug entries.

Provider actionIf a drug is included, follow step therapy requirements and submit authorization via the portal.

DocumentationThe document does not include detailed step therapy clinical criteria in the excerpts; refer to program-specific materials as needed.

UnitedHealthcare Provider Portal prior authorization tool

Portal toolUnitedHealthcare Provider Portal prior authorization tool — repeatedly cited as the required submission method for listed prior authorizations.

StepsSign in at UHCprovider.com, select Prior Authorization, then 'Create a new authorization' to begin submission.

ExamplesUsed for authorizations for Part B drugs such as Vyvgart (J9332), Vyvgart Hytrulo (J9334), Zolgensma (J3399).

Part B Step Therapy Program (program referenced for several drugs)

Program referencePart B Step Therapy Program — program referenced for several drugs across the document's drug lists.

ImplicationEntries marked as included in the program may require following step therapy protocols prior to approval.

SubmissionNotifications and prior authorizations for these drugs are submitted via the Provider Portal tool.

Part B Step Therapy Program

Portal requiredTo submit a prior authorization, use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at uhcprovider.com (sign in and create a new authorization).

Program applicabilitySome drugs in this section are part of the Part B Step Therapy Program; step therapy rules and notifications may apply.

Codes referencedExamples in this excerpt include HCPCS/J‑codes such as J9332, J9334, J3399 listed alongside portal submission instructions.

Part B Step Therapy Program

Tool namePrior Authorization and Notification tool — the UnitedHealthcare Provider Portal function providers must use to submit prior authorization requests.

Access stepsSign in at UHCprovider.com, select Prior Authorization, then 'Create a new authorization' to submit requests.

Applies toUsed for prior authorizations, notifications, and certain inpatient drug authorizations noted across the document.

UnitedHealthcare Provider Portal prior authorization tool

Primary instructionUse the UnitedHealthcare Provider Portal Prior Authorization and Notification tool at UHCprovider.com to submit prior authorization requests (sign in with One Healthcare ID).

Phone contactsPreferred Care Network: 866‑273‑9444; Preferred Care Partners: 800‑995‑0480; additional phone for inpatient portal guidance: 855‑851‑1127.

Portal stepsAfter sign‑in, select the Prior Authorization link and create a new authorization to submit requests or notifications.

Prior Authorization and Notification tool

Primary actionSubmit prior authorization via the UnitedHealthcare Provider Portal: sign in, choose Prior Authorization, then 'Create a new authorization'.

Alternate channelsPhone and fax numbers are provided in some sections for support or specific submission types (e.g., Phone: 855‑851‑1127; Fax: 844‑244‑9482).

NotePortal submission is emphasized repeatedly as the required workflow for most listed services and drugs.