Colorado Rocky Mountain Health Plans Prior Auth Update | OpenPayer
CurrentColorado Rocky Mountain Health PlansPolicy N/A
Prior Authorization Requirements for New York Medicaid
Lists prior authorization requirements and submission methods for participating providers delivering inpatient and outpatient services under UnitedHealthcare Community Plan of New York Medicaid; affects participating health care professionals and facilities.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior Authorization Requirements for New York Medicaid
Policy CodePolicy N/A
Change TypeNo material change noted
Effective DateFebruary 1, 2025
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-362-3368.
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Mixed
authorization flags
Coverage and Prior Authorization Criteria
Prior authorization requirements (partial)
Prior authorization requirements (partial) — Selected items and drug categories that require prior authorization. Consolidated from policy source.
ALL of the following
Cancer supportive care: Prior authorization is required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis. Specific HCPCS/J-codes that require prior authorization for oncology and (in some cases) non-oncology diagnoses include: J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122. See injectable medications section for details.
Includes injectable colony-stimulating factors and select anti-emetics and supportive agents.
Codes marked in source as requiring prior auth for oncology; some codes also require prior auth for non-oncology DX.
Injectable chemotherapy drugs: Chemotherapy injectables billed under J9000-J9999, Leucovorin (J0640), Levoleucovorin (J0641/J0642), Lupron Depot (J1950), drugs with Q-codes, and miscellaneous HCPCS (unassigned) codes will require prior authorization.
Submit prior authorization requests online per plan instructions.
Injectable medications (general): Many specialty and new-to-market injectable medications require prior authorization or predetermination. Examples listed in policy include Zoladex — J9202; Zolgensma — J3399; and other named agents. For unclassified/temporary or miscellaneous codes (e.g., C9090, C9149, C9151, C9166, C9172, C9399, J3490, J3590) prior authorization is required only for select products (examples provided in source).
Refer to 'Review at Launch' and the Plan's medication list for current requirements.
White blood cell colony-stimulating factors (codes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for both oncology and non-oncology diagnoses when specified.
See cancer supportive care and injectable medications sections for cross-reference.
Site of service - Outpatient hospital (partial list)CPT
67010
67041
67042
67105
67108
67113
67840
68320
Female genital systemCPT
57240
Female genital system (partial list)
57250
57461
57520
58561
58562
Various surgical system groupsCPT
57522
Gynecologic procedures (partial list)
58353
58558
38500
Hemic and lymphatic systems (partial list)
38510
49505
Hernia repair (partial list)
49650
10121
Integumentary system (partial list)
Selected single-procedure codesCPT
47000
Liver biopsy
54840
Male genital system
20680
Miscellaneous
Musculoskeletal system codes (partial)mixed
20552
Musculoskeletal procedure code (listed)
29835
Arthroscopy or related musculoskeletal procedure (listed)
G0260
Musculoskeletal related HCPCS (listed)
Nervous system and ophthalmologic codes (partial)CPT
64561
Nervous system procedure code (listed)
64640
Nervous system procedure code (listed)
65426
Ophthalmologic procedure code (listed)
Transplant/major surgery codes (partial)CPT
38232
Hematopoietic progenitor cell collection/related (listed with asterisk)
44132
Abdominal surgery code (listed)
47135
Hepatobiliary surgery code (listed)
Listed codesmixed
32853
32854
32855
32856
33930
33933
33935
33940
33944
33945
1–10 of 79
1/8
Cancer supportive care scope
ScopePrior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis.
Examples of CSF codesJ1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 (these codes also require PA when used for non-oncology diagnoses).
How Providers Submit Requests and What They Must Do
Prior Authorization
How to Submit Prior Authorization Requests
Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the phone numbers listed for specific service types. All planned, elective inpatient service requests require prior authorization. Prior authorization is not required for network or out-of-network emergent or urgent care. All non-emergent, out-of-network services require prior authorization regardless of place of service.
Online: Sign in with One Healthcare ID at UHCprovider.com → Prior Authorization and Notification tab
General phone contact: 866-362-3368
Prior Authorization
Examples of Codes and Services Requiring Prior Authorization
The following is a consolidated list of notable service categories and example CPT/HCPCS/J/Q/L codes that require prior authorization. This is not exhaustive — always check the Provider Portal for the complete and current list.
Examples include bariatric surgery (e.g., 43644, 43645, 43659, 43770, 43775, 43842–43848, 43860)
DME codes that require authorization when retail purchase or cumulative rental cost exceeds threshold (e.g., A4575, A9279, A9280, A9900, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0465–E0471, E0483, E0486)
Submission methodsSubmit PA requests via the Prior Authorization and Notification tool on UHCprovider.com or by phone (866-362-3368).
ExceptionsPrior authorization is not required for network or out-of-network emergent or urgent care.
Emergent or urgent care does not require prior authorization
DefinitionEmergent or urgent care does not require prior authorization.
Scope noteThis exception applies to both network and out-of-network emergent or urgent care per the document.
Policy Revision Timeline
February 1, 2025policy_effective_dateLatest
Policy became effective for UnitedHealthcare Community Plan of New York Medicaid prior authorization requirements.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior Authorization Requirements for New York Medicaid
Policy CodePolicy N/A
Change TypeNo material change noted
Effective DateFebruary 1, 2025
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-362-3368.
Other supportive drugsSelected anti-emetics and agents listed that require prior authorization (examples: J1454, J0185, J1453, J1627).
DME cost threshold
Threshold rulePrior authorization required only for the listed DME codes when retail purchase or cumulative rental cost exceeds the plan's cost threshold.
Genetic and molecular testing (including BRCA and many other molecular panels) requires prior authorization for outpatient testing. Providers must include required documentation and specify the performing laboratory when submitting authorization/notification.
Representative other codes and U-codes: 87505–87507, 0006M, 0007M, 0018U, 0022U, 0023U, 0026U, 0055U, 0060U, 0087U, 0088U, 0111U, 0129U, S3870
Prior Authorization
Gender Dysphoria Treatment (Surgical Codes)
Gender dysphoria-related surgical treatments require prior authorization. Some surgical CPT codes are tied to specific diagnosis codes for authorization.
Examples of surgical CPT codes listed: 55970, 55980, and a range of procedure codes mapped to gender dysphoria diagnosis codes (see Provider Portal for exact code-to-DX mappings)
Authorization requires submission of diagnosis (e.g., F64.x) and supporting clinical documentation
Prior Authorization
Home Health Care Prior Authorization Note
Home health care prior authorization applies only in outpatient settings, including services provided in the member's home. Verify which home health CPT/HCPCS codes require authorization before initiating services.
Example HCPCS/G-codes: G0156, G0162, G0299, G0300, G0493–G0496
Also includes S- and T- codes for certain home services (see Provider Portal)
Prior Authorization
Injectable Medications Prior Authorization
Many injectable medications (including chemotherapy, supportive care agents, and specialty biologics) require prior authorization. Some J/Q codes and certain temporary/unclassified codes have specific rules.
Injectable examples: J3262 (Acthar), J0800 (Adakveo), J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 (colony-stimulating factors — require PA for oncology and non‑oncology diagnoses)
Other injectable examples: J9202 (Zoladex), J3399 (Zolgensma), J9999/unclassified codes (may require PA for specific products such as Nulibry, Purified Cortrophin Gel, Rivfloza, Syfovre)
Chemotherapy injectable drug ranges (J9000–J9999) and miscellaneous/unclassified HCPCS for new-to-market agents require prior authorization; consult the Review at Launch policy and the Provider Portal
For some products (e.g., Cimzia) pre-notification is handled through partner vendors (Magellan) — confirm the required vendor phone number and process
Prior Authorization
Orthotics and Prosthetics Prior Authorization (Partial L-code List)
Orthotics and prosthetics require prior authorization for specified L-codes. The policy lists an extensive set of L-codes that require authorization; check the Portal for full details and any device-specific documentation requirements.
Non-emergent air ambulance transport (A0430, A0431) requires prior authorization
Prior Authorization
Proton Beam Therapy Prior Authorization
Proton beam therapy is an advanced radiation modality that requires prior authorization prior to initiation.
Relevant CPT codes: 77520, 77522, 77523, 77525
Submit requests via the Provider Portal or contact the number shown for advanced radiation services
Prior Authorization
Sleep Apnea Procedures and Sleep Studies Prior Authorization
Sleep apnea procedures/surgeries and sleep studies require prior authorization except where noted by specific state program exceptions. Confirm authorization requirements and applicable diagnosis coding when submitting.
Sleep apnea procedures and surgeries: prior authorization required (see Portal for codes and clinical criteria)
Sleep study CPT codes that commonly require prior authorization: 95805, 95807, 95808, 95810, 95811
Note: sleep study authorization exceptions may exist for certain state long-term services programs — verify before ordering
Prior Authorization
Spinal Surgery Prior Authorization
Spinal surgery and related procedures require prior authorization. A broad range of CPT codes for decompression, fusion, and instrumentation are listed in the policy and on the Provider Portal.
Examples of spinal surgery codes: 22100–22114, 22206, 22207, 22210, 22212, 22214, 22220, 22224, 22510–22511, 63030, 63040, 63042, 63045–63087, 63090, 63101–63102
Submit clinical documentation supporting medical necessity when requesting authorization
Prior Authorization
Stimulator Implantation Prior Authorization
Implantation of neurostimulators and similar implantable devices requires prior authorization. This includes spinal cord stimulators and other devices that send electrical impulses.
Representative device/procedure codes include 64590 and device HCPCS codes such as L8680, L8682, L8685–L8688
Authorization should include prior device trials, documentation of conservative therapy, and relevant diagnostic testing per Portal guidance
Prior Authorization
Transplants and CAR T Prior Authorization
Transplant and CAR T-cell therapy services require prior authorization and case management coordination through the UnitedHealthcare Community and State Transplant Case Management team.
For transplant and CAR T-cell therapy (examples: Abecma, Breyanzi, Carvykti, Kymriah, Lyfgenia, Tecartus, Yescarta, Zynteglo) call the Transplant Case Management team at 888-936-7246 or the number on the back of the member's ID card to initiate authorization and case management
Follow portal instructions for submitting required documentation and for coordination of care
Prior Authorization
VAD Notification and Fax Process
Ventricular assist devices (VADs) require notification and a specific fax workflow. Contact the number on the member's health plan ID card first; then fax the form provided by the nurse to Optum VAD Case Management.
Call the notification number on the back of the member's ID card to begin the process
Fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929
Relevant CPT/HCPCS codes include 33927, 33928, 33929, 33975, 33976, 33979, 33981–33983 and Q0507–Q0509 where applicable
Prior Authorization
Vein Procedures and Wound Vac Prior Authorization
Vein procedures and wound vacuum-assisted closure (wound vac) require prior authorization. Submit clinical documentation supporting medical necessity.
Wound vac examples: E2402 (and other relevant E/M HCPCS codes)
Related ruleAll non-emergent, out-of-network services still require prior authorization regardless of place of service.
EEG/Monitoring prior authorization
Inpatient video EEGPrior authorization is not required for outpatient hospital or ambulatory EEG services (inpatient video EEG distinction noted).
Cerebral seizure monitoringPrior authorization is required for inpatient cerebral seizure monitoring (examples: CPT 95700, 95711-95713).
Chemotherapy noteChemotherapy administration in outpatient hospital or ASC generally does not require prior authorization, but specific injectable chemotherapy drugs (J9000-J9999, J0640-J0642, J1950), Q-coded chemo drugs, and miscellaneous HCPCS chemo agents do require prior authorization.
Code rangesInjectable chemotherapy drugs requiring prior authorization include J9000-J9999 and specified leucovorin/levoleucovorin codes (J0640, J0641, J0642).
Q-coded and misc agentsQ-coded chemotherapy injectables and agents billed under miscellaneous HCPCS also require prior authorization.
Additional injectable drugsPolicy lists many injectable chemotherapy and supportive oncology HCPCS/J-codes requiring prior authorization; see injectable medications section for examples.
Home health care prior authorization note
ScopePrior authorization for home health care is required only when services are provided in outpatient settings, which includes the member's home.
Example codesExamples of home health codes listed: G0156, G0162, G0299, G0300, G0493.
NoteSome home health services may qualify but are not subject to the same DME retail/rental threshold rules.
Genetic/molecular testing prior auth
RequirementPrior authorization or prior notification is required for genetic and molecular testing performed in an outpatient setting.
Provider responsibilityRequesting laboratory must complete the prior authorization/notification process as indicated in the policy.
Example codesRepresentative codes include 81162, 81163, 81400-81408, 81410-81417, 81431-81432, 81435, 81507, 81518, 81519.
Prior notification
Prior notification for CimziaObtain prior notification for Cimzia through Magellan prior notifications at 800-788-4005.
ContextThis is listed as a prerequisite separate from standard prior authorization for injectable medications.
ReferencePolicy notes Cimzia prior notification in the injectable medications section.
Unclassified/temporary codes
Unclassified/temporary codes ruleUnclassified and temporary HCPCS/CPT codes (e.g., J3490, J3590, C9090, C9149, C9151, C9166, C9172, C9399) require prior authorization only for specific products named in the policy (examples include Nulibry, Purified Cortrophin Gel, Rivfloza, Syfovre, Amtagvi, Lantidra, Lenmeldy, Tecelra).
ExamplesPolicy names specific drugs associated with unclassified codes and notes which products trigger PA requirements.
ActionCheck the policy's injectable medications and unclassified codes sections to determine if a PA is required for a specific product billed under an unclassified/temporary code.
Prior notification (Cimzia)
Cimzia prior notificationPrior notification through Magellan is required for Cimzia (800-788-4005).
Location in policyReferenced in the injectable medications/prior notification section of the document.
Relation to PAThis prior notification is distinct from typical PA submission through UnitedHealthcare portal.
Orthotics/prosthetics prior authorization scope
ScopePrior authorization is required only for the orthotics and prosthetic items specifically listed in the policy; not all L-codes are universally subject to PA.
Retail purchase noteSome prosthetic entries specify PA is required when the retail purchase exceeds $500.
Additional noteAdvanced outpatient imaging (T-codes) also have PA requirements referenced nearby in the radiology section.
Prior Authorization and Notification tool
Tool namePrior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com) where providers submit authorization requests.
How to accessSign in with One Healthcare ID at UHCprovider.com and select the Prior Authorization and Notification tab on the dashboard.
Phone alternativeOr call the prior authorization phone numbers provided in the policy (examples: 866-362-3368 general; 866-889-8054 for some services).
Certain imaging/nuclear procedures
Imaging categoriesCertain CT, MRI, MRA, PET and nuclear cardiology procedures require prior authorization.
Submission methodSubmit PA requests through the Provider Portal Prior Authorization and Notification tool or call 866-889-8054 for details and CPT lists.
ReferenceSee radiology and advanced imaging sections for specific CPT/HCPCS codes requiring PA.
Prior authorization required
DefinitionPrior authorization required means the payer requires approval before performing the procedure for coverage eligibility.
Examples of services requiring PASleep apnea procedures/surgeries, sleep studies (exceptions for NY LTSS), spinal surgery, stimulator implantation, transplants and CAR T-cell therapies.
Transplant contactFor transplant and CAR T-cell therapy services contact the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or the number on the member's ID card.
Transplant/CAR T-cell therapy prior auth process
Contact for authorizationTransplant and CAR T-cell therapy services require prior authorization and coordination; call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the number on the member's ID card.
Listed CAR T productsExamples include Abecma, Breyanzi, Carvykti, Kymriah, Lyfgenia, Tecartus, Yescarta; policy lists these in the transplant section.
Procedure codesTransplant-related CPT/HCPCS codes are listed in the transplant/major surgery section; some codes (e.g., 38232) have oncology-only PA notes.
38232 oncology-only prior authorization
Specific code noteCode 38232 will only require prior authorization for an oncology diagnosis.
ContextThis is an exception within the transplant/major surgery code listings where most codes require PA but 38232 is oncology-diagnosis specific.
ReferenceSee transplant/major surgery section for surrounding codes and PA instructions.
Ventricular assist devices (VAD) notification
Notification requirementVentricular assist devices (VAD) require prior authorization/notification; providers must call the notification number on the member's ID card and then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.
Example procedure codesExamples in the VAD and vein procedures section include 33927–33983 and 37700, 37718, 37722, 37765, 37766.
Wound vac noteWound vacs (E2402) are noted as requiring prior authorization in the same section.
Unclassified codes / drug examples
Examples of unclassified drug entriesUnclassified codes referenced include Amtagvi, Lantidra, Lenmeldy, Tecelra and other products noted under unclassified/temporary codes.
PA for unclassified codesUnclassified/temporary codes (J3490/J3590, C9399, etc.) require PA only for specified products; verify product-specific PA requirements in the policy.
ActionWhen billing under an unclassified/temporary code, confirm whether the named product on the policy triggers prior authorization before submission.