CurrentColorado Rocky Mountain Health PlansPolicy N/A

Rocky Mountain Health Plans Medicare Advantage and Dual-Special Needs Plans/DSNP - Effective Oct. 1, 2024

A plan-level prior authorization and notification list for services requiring advance approval for UnitedHealthcare Rocky Mountain Health Plans Medicare Advantage and Dual-Special Needs Plans (D-SNP), including how to request authorization, contact points, and many CPT/HCPCS/ICD-10 codes that require prior auth or are exempted.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRocky Mountain Health Plans Medicare Advantage and Dual-Special Needs Plans/DSNP - Effective Oct. 1, 2024

Policy CodePolicy N/A

Change TypePeriodic update (no material change)

Effective DateOct 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests via UHCprovider.com/priorauth or the Prior Authorization and Notification tool; non-participating providers may fax to 800-262-2567 or 970-255-5681.

SourceLink

100+Sample CPT/HCPCS codes listed in Part 1

eviCoreThird-party manager used

UHCproviderPrimary contact portal

150+Codes listed in this part

DME/Procedures

Policy overview

This is a plan-level prior authorization and notification requirements list for UnitedHealthcare Rocky Mountain Health Plans Medicare Advantage and Dual‑Special Needs Plans (D‑SNP). It defines which services require prior authorization, how to request authorization (participating providers use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool; non‑participating providers may fax to 800‑262‑2567 or 970‑255‑5681), and identifies third‑party management by eviCore (web: evicore.com, phone: 800‑792‑8750). The list is updated periodically; the provider portal contains the most current information. The policy is effective 2024-10-01.

Key facts (compact)

Effective dateEffective October 1, 2024

PayerColorado Rocky Mountain Health Plans (UnitedHealthcare Rocky Mountain Health Plans Medicare Advantage and D‑SNP)

Policy subjectPrior authorization requirements for Rocky Mountain Health Plans Medicare Advantage and D‑SNP

Primary submission portalUHCprovider.com/priorauth (Prior Authorization & Notification tool on UnitedHealthcare Provider Portal)

Third-party managereviCore (evicore.com; phone 800-792-8750)

Behavioral health contactBehavioral Health Services authorization phone: 888-282-8801

Admitting facility notificationAdmitting facility must notify plan: 800-416-2157 (option 4) or 970-248-5197

What providers must do

Prior Authorization

Submit prior authorization requests via Provider Portal

Participating providers: submit PA requests and supporting documentation via the UnitedHealthcare Provider Portal (UHCprovider.com/priorauth > Advance Notification and Clinical Submissions Requirements > Select a Plan Type) . Non‑participating providers: fax requests to 800-262-2567 or 970-255-5681.

Portal path: UHCprovider.com/priorauth > Advance Notification and Clinical Submissions Requirements > Select a Plan Type
Fax (non‑participating): 800-262-2567 or 970-255-5681

Prior Authorization

Use eviCore for managed services

For services managed by eviCore, request prior authorization online at evicore.com or by phone.

Prior authorization criteria and notes

General Prior Authorization Requirement

Prior authorization is required for the services listed below except where specific exemptions are noted. Providers must obtain authorization before rendering services unless the service is emergency or urgent care, or expressly exempted by diagnosis or procedure guidance.

Prior authorization is required when UnitedHealthcare Rocky Mountain Health Plans is the primary payer.

Services that are not a benefit of the member's Evidence of Coverage (EOC) will not be authorized.

Prior authorization is not required for emergency or urgent care.

Out-of-network physicians, facilities and other health care providers must request prior authorization for all procedures and services, excluding emergent or urgent care.

Key billing rules and denial risks

Prior Authorization

Obtain prior authorization before service

Obtain prior authorization before providing or billing services listed in this policy. Requests should cite the specific CPT/HCPCS/L-code(s) from the policy when seeking authorization.

Lack of prior authorization may lead to claim denial
Include the specific CPT/HCPCS/L codes from this policy when requesting PA

Documentation Required

Gender dysphoria claims require supporting diagnosis

When billing gender dysphoria surgical procedures, include a supporting diagnosis code from the specified list; PA is required.

Required DX codes: F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890

Codes requiring prior authorization (grouped)

DME HCPCS - mobility, orthotics, prosthetics (selected L-codes)HCPCS

L5706	Ankle-foot orthosis, prefabricated, off-the-shelf
L5707	Ankle-foot orthosis, custom molded
L5710	Knee orthosis, prefabricated
L5711	Knee orthosis, custom fabricated
L5712	Knee-ankle-foot orthosis, prefabricated
L5714	Knee-ankle-foot orthosis, custom
L5716	Hip-knee-ankle-foot orthosis, prefabricated
L5718	Hip-knee-ankle-foot orthosis, custom
L5722	Spinal orthosis, thoracolumbosacral, prefabricated
L5724	Spinal orthosis, thoracolumbosacral, custom

1–10 of 17

1/2

Ophthalmology / Eye procedure CPT codesCPT

65770	Corneal transplant, lamellar
65785	Corneal patch graft
66989	Destruction of lesion of eyelid
66991	Repair of eyelid
66999	Unlisted procedure, anterior segment of eye
67299	Unlisted phototherapy procedure of retina
67399	Unlisted strabismus procedure
67599	Unlisted oculoplastic procedure
67900	Repair of eyelid laceration
68399	Unlisted procedure, ear

1–10 of 25

1/3

Biologics, Injectables and Named Drugs (J, C, Q codes)mixed

A9590	Radioisotope diagnostic kit
A9606	Autologous cellular product
C9149	Injection, investigational biologic
C9151	Stem cell, autologous, processing
J0129	Injection, immune globulin, non-specific
J0178	Injection, aflibercept, 1 mg
J0179	Injection, brolucizumab, 1 mg
J0222	Injection, tetrabenazine
J0223	Injection, deutetrabenazine
J0225	Injection, other drug

1–10 of 79

1/8

Q-codes, Prosthetic and Miscellaneous SuppliesHCPCS

Q4130	Delivery system, enteral feeding
Q4132	Enteral nutrition pump
Q4133	Enteral feeding set
Q4134	Enteral feeding bag
Q4135	Enteral feeding syringe
Q4136	Enteral feeding tube
Q4137	Enteral feeding extension set
Q4138	Enteral feeding skin barrier
Q4139	Enteral feeding kits
Q4140	Enteral nutrition supplement

Ophthalmic / Eye injectable and Q codesHCPCS

Q4141	Ophthalmic therapeutic agent
Q4142	Ophthalmic diagnostic agent
Q4143	Ophthalmic implant
Q4145	Intraocular lens
Q4146	Ophthalmic insert
Q4147	Ocular spacer
Q4148	Ocular implant, posterior
Q4149	Ocular implant, anterior

Durable Medical Equipment - broad lists (selected)HCPCS

E2222	Nebulizer, handheld
E2224	Tracheostomy tube, disposable
E2225	Suction catheter, sterile
E2226	Feeding pump, enteral
E2311	Feeding tube, gastrostomy
E2228	Portable suction device
E2313	Gastrostomy button
E2321	Enteral feeding set, extension
E2322	Enteral feeding administration set
E2323	Enteral feeding pump set

1–10 of 17

1/2

Orthotics and Prosthetics - expanded L-codesHCPCS

L5780	Protective boot
L5781	Protective shoe
L5782	Diabetic shoe insert
L5785	Shoe modification, depth inlay
L5790	Foot orthotic, prefabricated
L5795	Foot orthotic, custom
L5810	Ankle orthosis, prefabricated
L5811	Ankle orthosis, custom
L5812	Knee orthosis, prefabricated
L5814	Knee orthosis, custom

1–10 of 16

1/2

Extensive L-code continuationHCPCS

L5940	Lumbosacral orthosis
L5950	Sacroiliac orthosis
L5960	Hip-knee-ankle-foot orthosis
L5961	HKAFO components
L5962	KAFO components
L5964	Knee orthosis, stance control
L5966	Prosthetic socket modification
L5968	Prosthetic alignment components
L5969	Prosthetic liner
L5970	Prosthetic suspension

1–10 of 14

1/2

Miscellaneous HCPCS, CPT, and temporary codesmixed

0308T	Arthroplasty, resurfacing (temporary)
0378T	Arthroplasty, implant removal (temporary)
0063U	Molecular pathology test
0064U	Genetic test
0065U	Laboratory test, novel
0066U	Diagnostic assay
0253T	Advanced arthroplasty procedure
34839	Urethral sling
53451	Repair of penile fracture
53452	Penile prosthesis

1–10 of 22

1/3

Key definitions

Definitions

Prior authorizationProcess where providers seek approval before rendering a service as required by UnitedHealthcare policy.

Advance notificationRequirement for providers to give timely communication so UnitedHealthcare can perform prospective, concurrent and retrospective review.

Prior Authorization and Notification AppOnline submission tool (e.g., eviCore or UnitedHealthcare Provider Portal tool) used to request prior authorization or provide notification for services.

Common questions

Note

Portal / Online

Note

eviCore (managed services)

Note

Behavioral health authorization

Note

Admitting facility notification

Policy revision history

2024-10-01Effective dateLatest

Policy effective date for UnitedHealthcare Rocky Mountain Health Plans MA and D-SNP

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRocky Mountain Health Plans Medicare Advantage and Dual-Special Needs Plans/DSNP - Effective Oct. 1, 2024

Policy CodePolicy N/A

Change TypePeriodic update (no material change)

Effective DateOct 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests via UHCprovider.com/priorauth or the Prior Authorization and Notification tool; non-participating providers may fax to 800-262-2567 or 970-255-5681.

SourceLink

On This Page

Prior Authorization

Behavioral health authorization phone

Authorize behavioral health services (mental health and substance use) by calling the behavioral health authorization line.

Behavioral health codes: 90899, 97151, 97152, 97153, 97154, 97155, 97156, 97157
Phone: 888-282-8801

Prior Authorization

Admitting facility and app notifications

Admitting facilities must notify the plan by phone when required; providers should submit prior authorization and notifications using the Prior Authorization and Notification App.

Admitting facility phone: 800-416-2157 (option 4)
Alternate admitting facility phone: 970-248-5197
Use the Prior Authorization and Notification App to submit requests

Documentation Required

Documentation & benefit verification

Confirm the service is a benefit in the member's Evidence of Coverage (EOC) before requesting prior authorization, and include the specific CPT/HCPCS/U-code for the device, procedure or DME in the authorization request.

Prior Authorization

Unclassified / temporary codes & specialty drug billing

Unclassified/temporary and unspecified J-codes and named drugs billed under unclassified codes require prior authorization.

Unclassified/temporary codes: C9172, C9399, J3490, J3590
Named drug examples: Amvuttra, Beqvez — PA required when billed under unclassified codes

Billing Rule

Additional billing rules & PA paths

Additional billing rules and authorization paths: home health services, many medical supplies (Q-codes) and radiology have specific PA requirements or are managed by eviCore. Obtain authorization before service to avoid denial.

Home health codes: 99600, G0248, G0249, G0250, S9364–S9368 require PA
Medical/surgical supplies identified by Q-codes (e.g., Q4101, Q4103, Q4104, Q4105) require PA
Many radiology services are managed by eviCore (notification/PA through eviCore)
Reminder: obtain authorization prior to service to avoid denial

Advance notification and prior authorization requests should be submitted via the RMHP/UnitedHealthcare prior authorization portal when possible; non-participating providers may submit requests by fax to the numbers below.

Submission and Authorization Process

Submission and authorization processes and contact points for prior authorization requests.

Participating providers: Submit prior authorization requests and supporting documentation through UHCprovider.com/priorauth > Advance Notification and Clinical Submissions Requirements > Select a Plan Type (Rocky Mountain Health Plans) — use the portal for fastest processing and to attach clinical documentation.

Non-participating providers: Fax requests and supporting documentation to 800-262-2567 or 970-255-5681.

eviCore services: Certain specialty services (as indicated in the RMHP prior authorization lists) are managed by eviCore. eviCore website: evicore.com; phone: 800-792-8750.

Behavioral health services (including mental health and substance use disorders): Call the designated behavioral health line at 888-282-8801. Many behavioral health services are managed through a designated behavioral health network and may have separate prior authorization rules.

Notification by admitting facility (for inpatient admissions): Phone 800-416-2157 option 4 or 970-248-5197.

Provider note: Prior authorization is required under the direction of the UnitedHealthcare Health Services Department and is essential for prospective, concurrent and retrospective review. Failure to obtain required prior authorization may result in claim denial.

Portal tool contact details: UHCprovider.com/priorauth (Advance Notification and Clinical Submissions Requirements) — use the portal first; see the fax and phone numbers above for alternate submission methods.

Diagnosis Codes Exempt from Prior Authorization (Breast reconstruction context)

The following diagnosis codes, when present in the breast reconstruction context, do NOT require prior authorization for associated reconstruction procedures.

Exempt diagnosis codes (breast reconstruction context): Z85.3, C50.011, C50.012, C50.021, C50.022, C50.031, C50.032, C50.041, C50.042, C50.111, C50.112, C50.121, C50.122, C50.131, C50.132, C50.141, C50.142, C50.211, C50.212, C50.221, C50.222, C50.231, C50.232, C50.241, C50.242, Z90.11, Z90.12

Operational note: When these diagnosis codes are billed and the procedure is for breast reconstruction related to mastectomy or cancer treatment as documented in the medical record, prior authorization for the reconstruction procedure is not required. If other diagnoses are used or the clinical context differs, standard prior authorization requirements apply.

Gender dysphoria surgical codes when billed with specific DX codes

Gender dysphoria–related surgical procedures require documentation of the primary diagnosis. When billed with the specified diagnosis codes, the listed surgical CPT codes are subject to the combined requirement (both diagnosis AND procedure) as shown below.

ALL of the following

At least one of the following diagnosis codes must be present: F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 (history of gender dysphoria or related condition).
The surgical procedure billed must be one of the following CPT codes: 19303, 19304, 19316, 19318, 19350, 67900, 67901, 67902, 15820, 15734, 15738, 15740, 15750, 20926, 21210, 21220, 21230.

Sample CPTs (gender dysphoria surgical codes): 15771, 15772, 15773, 15774, 15776, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 19303

Billing Rule

Handling unclassified/temporary codes

When named drugs or supplies are billed under unclassified/temporary or unspecified codes, prior authorization is required.

Unclassified/temporary and unspecified codes: C9172, C9399, J3490, J3590
Note: named drugs billed under these unclassified codes (e.g., Amvuttra, Beqvez) require prior authorization

Note

Radiology managed by eviCore

Many radiology services require prior authorization or notification and are managed by eviCore; submit requests via the eviCore website or follow the Provider Portal radiology/PA instructions.

eviCore web: evicore.com; phone: 800-792-8750
For radiology, use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or eviCore as noted