Colorado Rocky Mountain Health Plans Prior Auth Policy | OpenPayer
CurrentColorado Rocky Mountain Health PlansPolicy N/A
Prior Authorization Requirements and Submission Methods
Governs prior authorization requirements and submission methods for UnitedHealthcare Community Plan of Louisiana participating health care professionals for inpatient and outpatient services; describes services and CPT/HCPCS codes that require prior authorization. Affects participating providers and facilities (in-network and out-of-network).
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior Authorization Requirements and Submission Methods
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateDec 1, 2023
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com or call 877-842-3210.
No material clinical or coverage changes in this revision.
877-842-3210phone number for prior authorization
Online portalPrior Authorization tool
MultipleService categories requiring PA
PA requiredEnteral therapy
$500Orthotics/prosthetics threshold
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contact numbersTransplant/CAR T contact
Services Requiring Prior Authorization
High-level coverage stance — Services and codes listed below require prior authorization; emergency and urgent care do not require prior authorization.
Services and codes listed below require prior authorization unless otherwise noted. Emergency and urgent care do not require prior authorization. For many services, instructions for how to obtain prior authorization are included with the code lists; when not included, contact the number on the member's health plan ID card or use the payer portal tools referenced.
ALL of the following
Prior authorization is required for the listed services and codes unless an exception is noted (for example, emergency and urgent care).
High-level coverage stance applies across all groups below.
Examples of service categories requiring prior authorization
See payer for full code list and submission details.
Bariatric surgery and obesity-related procedures (examples of CPT codes: 43644, 43645, 43659, 43770, 43775, 43842, 43845).
Behavioral health services: prior authorization required for many behavioral health services; some plans route behavioral health through a designated behavioral health network. For mental health and substance use services, call the number on the member's ID card. For ABA therapy, submit via fax or Provider Express as directed.
Durable medical equipment (DME): prior authorization required only for specified HCPCS codes and/or when retail purchase or cumulative rental costs exceed plan thresholds (examples: A9900, E0265, E0266, E0328, E0329, E0445, E0465, E0466, E0656, K0880, K0884, K0885, K0886, K0890, K0891, S1040, V5269, V5272).
Injectable medications and chemotherapy administered outpatient: many J-codes and related HCPCS require prior authorization. Specific biologic, chemo, and supportive care drugs listed (e.g., J0180, J0885, J0897*, J1442, J1447, J1551, J1554, J1555, J1561, J1569, J2506, Q5101, Q5108, Q5110, Q5111, Q5122, Q5125); see injectable medications list and Review at Launch guidance for new-to-market drugs.
For certain codes (e.g., unclassified/temporary C9172, C9399, J3490, J3590) prior authorization applies only for specific products (e.g., Nulibry, Rivfloza, Revcovi). For J0897 prior authorization required for non-oncology diagnosis.
Cancer supportive services and colony stimulating factors (examples: J1449, J2820, J1447, J2506, J0897 for denosumab when non-oncology).
Inpatient admissions and post-acute services: prior authorization and notification of admission date required for acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, and selected post-acute facilities.
Imaging / Radiology: prior authorization or at minimum provider notification is required for advanced outpatient imaging procedures, nuclear medicine/nuclear cardiology, PET scans (examples: 78608–78612, 78811–78816, A9515, A9526, A9552, A9580, A9587–A9588, G0219, G0235). Providers ordering advanced outpatient imaging are responsible for prior notification prior to scheduling.
Spinal surgery (examples include 22114, 22210–22224, 22532, 22533, 22548, 22551, 22554, 22558, 22586, 22600, 22633, 22808).
Orthognathic surgery (examples: 21240, 21242, 21244–21249, 21255, 21246–21248 listed).
Orthotics and prosthetics: prior authorization required only for items with a retail purchase or cumulative rental cost greater than $500 (examples: L0170, L0464, L0482, L0484, L0486, L0631, L0700, L0710, L0810, L0820, L0830, L0999, L1000, L1200, L1300, L1310, L1680, L1685, L1700, L1710, L1720, L1730, L1755, L1820).
Transplants and CAR T-cell therapy: prior authorization required (examples of CPT/HCPCS: 63685, 64553, 64568, 64570). For transplant and CAR-T services call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member's ID card.
Ventricular assist devices (VAD): prior authorization required; VAD devices and supplies are not covered. For notification, call the number on the member's ID card and fax provided form to Optum VAD Case Management Team at 855-282-8929.
Personal care services and pediatric day services: prior authorization required for listed codes (examples: T1019, T1025, T1026, S9123, S9124).
Vein procedures for venous disease and varicose veins: prior authorization required.
Where shown, specific submission instructions apply: use the payer’s Provider Portal Prior Authorization and Notification tool (UHCprovider.com → Provider Portal) for many requests; call the phone numbers listed (for radiology: 866-889-8054; for prior auth portal help: 888-397-8129; for transplants: 888-936-7246).
Follow specific submission guidance in each group; check the payer portal or policy pages for the most current code lists and Review at Launch updates.
Prior authorization criteria by service group — Services and codes listed require prior authorization or notification as indicated.
Prior authorization is required for the service groups and codes listed below. Where provided, the code examples are illustrative — consult payer resources for complete lists and submission instructions. When portal submission is available, use the Prior Authorization and Notification tool on the Provider Portal; phone numbers are provided for select service types.
Bariatric surgery and obesity-related services: CPT examples 43644, 43645, 43659, 43770, 43775, 43842, 43845.
Behavioral health services: call the number on the member’s ID card for mental health and substance use services; ABA therapy via fax/Provider Express.
Imaging prior authorization/notification — Radiology and imaging
Advanced outpatient imaging and radiology procedures require prior authorization or at minimum provider notification before scheduling. Nuclear medicine, nuclear cardiology, and PET scans specifically require prior authorization.
ALL of the following
Care providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling the procedure and for obtaining prior authorization where required.
Use the Prior Authorization and Notification tile on the Provider Portal or call the radiology prior authorization number.
Radiology contact: use the Prior Authorization and Notification tile on the Provider Portal dashboard, or call 866-889-8054 for radiology prior authorization and details.
For full CPT lists and PET scan codes that require prior authorization, see the payer radiology prior authorization page (UHCprovider.com/LAcommunityplan > Prior Authorization and Notification > Radiology Prior).
PET scan example codes requiring prior authorization
Orthotics/Prosthetics PA criteria (cost-based) — Orthotics and prosthetics
Orthotics and prosthetics require prior authorization only when the item is purchased at retail or when cumulative rental costs exceed the plan's threshold (typically > $500). Specific HCPCS/L-codes listed below are examples subject to that threshold.
ALL of the following
Prior authorization required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost greater than $500.
Example orthotics/prosthetics codes (subject to cost threshold)
L0170, L0464, L0482, L0484, L0486
L0631, L0700, L0710, L0810, L0820, L0830
L0999, L1000, L1200, L1300, L1310
Surgery and specialized therapy PA — Selected surgical and therapy services
Selected surgical and specialized therapy services require prior authorization. Where specific CPT/HCPCS codes are listed, those examples illustrate the scope of services requiring review. Follow specialty submission instructions where provided.
Joint replacement and transport sample CPT/HCPCS codesmixedCovered
A0430
Non-emergent air ambulance transport
A0435
Non-emergent air ambulance transport
27120
Total hip replacement
27446
Knee replacement (example)
Orthotics and prosthetics HCPCS codes (examples)HCPCSCovered
L0170
Orthotics / prosthetics example codes
L0482
Orthotics / prosthetics
L1000
Prosthetic related code
Orthognathic surgery CPT codes (partial list)CPTCovered
21240
Orthognathic surgery (code listed in section)
21242
Orthognathic surgery
21244
Orthognathic surgery
21245
Orthognathic surgery
Orthotics and prosthetics HCPCS L-codes (extensive list)HCPCSCovered
L0170
Orthotics/prosthetics HCPCS L-codes (many listed)
L0486
Orthotics/prosthetics example HCPCS
L5210
Orthotics/prosthetics example HCPCS
Radiation and proton therapy CPT codesCPTCovered
77520
Proton beam therapy
77014
Radiation therapy imaging (example)
77331
Radiation therapy planning
PET scan CPT/HCPCS codesmixedCovered
78608
PET scan codes
78813
PET scan / nuclear medicine codes
A9515
PET-related HCPCS
ENT and skin substitute codesCPT | HCPCSCovered
30400
Rhinoplasty
31295
Sinuplasty
Q4101
Skin substitute (example)
Spine and device codesCPT | HCPCSCovered
22533
Spinal surgery example code
E0748
Stimulator/code for implantation device
Transplant/CAR T and miscellaneous drug codesCPT | HCPCS | NDCCovered
63685
Spinal/neurosurgical procedure
J3490*
Unclassified drugs - requires PA
DME cost threshold — inv-23
DME cost thresholdCertain DME prior authorization is subject to a retail purchase or cumulative rental cost threshold (see Home health services).
PA applies only to listed DME codesPrior authorization is required only for the DME codes listed in the policy (codes shown in DME sections).
Reference for cost threshold detailsSee Home health services section for how the retail purchase or cumulative rental threshold is applied to DME codes.
How to Submit Prior Authorization and Provider Responsibilities
Prior Authorization
Prior Authorization Required — Service-specific
Prior authorization is required for many specific services. Submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the phone number on the member's ID card when noted. Emergency and urgent care are excluded.
Service-specific prior authorization notes: Abortion, bariatric surgery, behavioral health (including ABA therapy — submit via fax or Provider Express), bone growth stimulators (20979), BRCA genetic testing (81162–81165), cancer supportive services and many injectable chemotherapy drugs (J9000–J9999 and specific J-/Q-codes listed in the Injectable medications section), enteral/in-home nutritional therapy (B4035–B4161, B9002, B9998), functional endoscopic sinus surgery (31255–31288), home health services (G0299, T1000, G0300, S9123–S9124), and others listed in this policy require prior authorization.
Prior Authorization
Spinal Surgery and Neurostimulator Devices — Prior Authorization
Spinal surgery procedures require prior authorization. This includes a broad set of CPT codes for cervical, thoracic and lumbar procedures as listed below; submit prior authorization requests before elective surgery.
Key Terms and Definitions
Prior authorization — inv-45
Definition of prior authorizationA requirement to submit and obtain approval before providing certain non-emergency services or procedures; requests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone (see contact numbers).
Submission methodsSubmit prior authorization requests online using the Prior Authorization and Notification tool on UHCprovider.com or call the phone numbers provided in the policy (e.g., 877-842-3210; some services use 888-397-8129).
Emergency/urgent care exceptionPrior authorization is not required for emergency or urgent care services.
Behavioral health referrals — inv-46
Behavioral health referral instructionsWhen referring for mental health or substance use services, call the number on the member's health plan ID card.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior Authorization Requirements and Submission Methods
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateDec 1, 2023
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com or call 877-842-3210.
Cancer supportive services and chemotherapy: many injectable chemotherapy and supportive drugs (J9000–J9999 range and specified J/Q codes) require prior authorization; submission via Provider Portal is preferred.
Durable medical equipment (DME) and orthotics/prosthetics: prior authorization required for listed HCPCS codes and when retail or cumulative rental costs exceed plan thresholds (see lists).
Enteral nutrition and home nutritional therapy: examples B4034–B4036, B4100, B4149, B4150, B4152–B4161, B9002, B9998.
Injectable medications (extensive list): see injectable medications list (examples include J0180, J0219, J0554, J0885, J1306, J1411, J1413, J1442, J1447, J1551, J1554, J1555, J1561, J1569, J2329, Q5121, Q5103).
Imaging and radiology: advanced outpatient imaging and nuclear medicine/nuclear cardiology require prior authorization or notification; PET scans examples 78608–78612, 78811–78816, G0219, G0235, A9515–A9588.
Procedures: rhinoplasty/septoplasty (30400–30462), sinuplasty (31295–31298), functional endoscopic sinus surgery (31255–31288 range), spinal surgery (see spinal code groups), orthognathic surgery (21240–21255 range).
Transplants and CAR T-cell therapy: CPT/HCPCS examples 63685, 64553, 64568, 64570; call Transplant Case Management Team at 888-936-7246 for authorization and coordination.
Ventricular assist devices: prior authorization required; devices and supplies not covered. Notification and fax instructions to Optum VAD Case Management Team at 855-282-8929.
Inpatient and post-acute facility admissions: prior authorization and admission-date notification required for acute hospitals, inpatient rehab, critical access, LTACs, and selected post-acute facilities.
Personal care and pediatric day services: prior authorization required for codes such as T1019, T1025, T1026, S9123, S9124.
Operational notes: when listing includes an asterisk or special note (for example: J0897 prior auth for non-oncology diagnosis; certain Q/C codes require prior auth only for non-oncology diagnoses), follow the annotated guidance. Pre-determination is recommended for new-to-market medications per Review at Launch policy.
Vein procedures and certain interventional procedures: prior authorization required (see payer lists).
Transplants and CAR T-cell therapies: prior authorization required; contact Transplant Case Management at 888-936-7246.
Ventricular assist devices (VAD): prior authorization required; devices and supplies are not covered; follow notification and fax process to Optum VAD Case Management at 855-282-8929.
Operational note: for inpatient/post-acute admissions, prior authorization and notification of admission date are required for the applicable facility types; follow the member ID card instructions or the portal workflow for notifications.
CGM benefit note — inv-24
CGM benefit change (effective 12/1/23)Effective 12/1/23: some continuous glucose monitors are covered under the Pharmacy benefit only; pharmacy prior authorization is managed by Magellan Medicaid Administration (MMA).
MMA contact for pharmacy PAContact Magellan Medicaid Administration at 1-800-424-1664 or lamcopbmpharmacy.com for pharmacy prior authorization for CGMs.
Codes referencedPolicy lists CGM-related HCPCS/CPT codes (examples: A4239, A9274, A9276, A9277, A9278, E2102, E2103) with benefit notes in the CGM section.
Orthotics/prosthetics PA thresholdRetail purchase or cumulative rental cost over $500 requires prior authorization.
PA applies only when cost exceeds thresholdPrior authorization is required only for orthotics and prosthetics with a retail purchase or cumulative rental cost above $500.
Example HCPCS codes subject to thresholdPolicy lists example L-codes (e.g., L0170, L0482, L0486, L1000) in the orthotics/prosthetics section; these are subject to the cost-based PA rule.
Orthotic/prosthetic PA cost threshold — inv-26
Orthotic/prosthetic PA cost thresholdRetail purchase or cumulative rental cost greater than $500 requires prior authorization.
Threshold applicationThe cost threshold applies to both retail purchases and cumulative rentals for orthotic and prosthetic items listed in the policy.
How to determine applicabilityCheck the orthotics and prosthetics section codes (L-codes) — PA is required only when the item’s retail or cumulative rental cost exceeds $500.
Spinal surgery codes include (but are not limited to): 22114, 22210, 22212, 22220, 22224, 22532, 22533, 22548, 22551, 22554, 22558, 22586, 22600, 22633, 22808, 63250–63272, 63286, 63300–63306, and other listed spinal procedure codes.
ENT Procedures and Skin Substitutes — Prior Authorization
ENT procedures including rhinoplasty, septoplasty and sinuplasty require prior authorization. Select skin substitute products also require prior authorization.
Transplants and CAR T‑cell Therapy — Prior Authorization & Contact Instructions
Transplant procedures and CAR T‑cell therapies require prior authorization and coordination with the UnitedHealthcare Community and State Transplant Case Management Team. Call the team or the notification number on the member's ID card before proceeding.
Transplant-related CPT codes listed in this policy (examples include 38208, 38210–38215, 38232, 38240–38242 and many other surgical transplant codes) require prior authorization.
For transplant and CAR T‑cell therapies (including Abecma, Breyanzi, Kymriah, Yescarta): call UnitedHealthcare Community and State Transplant 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 and coordinate case management.
Prior Authorization
VAD, Wound VAC, and Miscellaneous Codes — Prior Authorization & VAD Notification
Ventricular assist devices (VAD), wound VACs and certain miscellaneous device/drug codes require prior authorization and special notification steps. Follow the notification and fax instructions to Optum VAD Case Management when indicated.
Ventricular assist devices (VAD): prior authorization required; VAD device and supplies are not covered. For notification, call the number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.
Wound VAC (E2402) requires prior authorization.
Certain miscellaneous/temporary/unclassified drug codes (for example C9399, J3490, J0897 and others flagged in the Injectable medications section) may require prior authorization or have special handling — see Injectable medications and Review at Launch guidance.
Prior Authorization
Vein Procedures — Prior Authorization
Vein procedures for treatment of venous disease and varicose veins require prior authorization. Ensure prior authorization is obtained for the appropriate ablation or removal procedures before scheduling.
Prior authorization is required for removal and ablation of main trunks and named branches of the saphenous veins.
ABA therapy submission
For ABA therapy, submit requests via fax or Provider Express as indicated in the policy.
Use member ID card for contactBehavioral health services generally require following the contact instructions shown on the member's ID card for referrals and PA.
Review at Launch for New to Market Medications — inv-47
Review at Launch policyThe Review at Launch for New to Market Medications policy lists newly FDA-approved drugs requiring review; pre-determination is highly recommended for drugs on that list.
Where to find the policyThe Review at Launch policy is available at UHCprovider.com > Menu > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.
How to submit PA for listed drugsFor prior authorization of injectable/new-to-market drugs, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.
Post-acute inpatient services — inv-48
Definition of post-acute inpatient servicesIncludes acute care hospitals, acute inpatient rehabilitation, critical access hospitals, and long-term acute care hospitals for which prior authorization and notification of admission date are required.
Admission notification requirementPrior authorization and notification of the admission date are required for these post-acute inpatient settings as specified in the policy.
How to submitSubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129 for applicable inpatient injectable medications and admissions.
Advanced outpatient imaging procedure — inv-49
Definition of advanced outpatient imaging procedureAdvanced outpatient imaging procedures include certain CT, MRI, MRA, nuclear medicine, nuclear cardiology and PET studies that require prior notification or authorization before scheduling.
Provider responsibilityCare providers ordering an advanced outpatient imaging procedure are responsible for providing notification prior to scheduling the procedure.
Submission methods and contactSubmit notifications/requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the radiology contact number provided in the policy (e.g., 866-889-8054 where noted).
Orthotics/prosthetics PA threshold — inv-50
Orthotics/prosthetics PA thresholdOrthotics and prosthetics are subject to prior authorization when retail purchase or cumulative rental cost exceeds $500.
PA applies only above thresholdPrior authorization is required only for orthotic and prosthetic items with retail purchase or cumulative rental cost greater than $500; items below that threshold do not require PA per the policy.
Example codes listedPolicy lists numerous L-codes (examples include L0170, L0486, L1000) in the orthotics and prosthetics section that are subject to the cost-based PA rule.
Ventricular assist devices (VAD) — inv-51
Definition of Ventricular Assist Device (VAD)Ventricular assist device (VAD): a mechanical pump that takes over the function of the damaged heart ventricle and restores normal blood flow.
PA and notification for VADPrior authorization is required for VADs; providers must call the notification number on the member's ID card then fax the form to the Optum VAD Case Management Team at 855-282-8929.
Coverage notePolicy states VAD device and supplies are not covered (additional details in VAD section).