Colorado Rocky Mountain Health Plans Prior Auth | OpenPayer
CurrentColorado Rocky Mountain Health PlansPolicy N/A
Prior authorization requirements — Texas STAR (codes and submission instructions)
Lists prior authorization requirements for participating UnitedHealthcare Community Plan of Texas STAR providers for a variety of procedures and drugs, with instructions for submitting requests and specific CPT/HCPCS/J-codes that require prior authorization and associated effective dates.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior authorization requirements — Texas STAR (codes and submission instructions)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateApr 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (One Healthcare ID) or use 24/7 chat as directed on the Contact us page.
No material clinical or coverage changes in this revision.
manyprocedure and drug code entries listed
online/chatsubmission methods offered
Texas STARprogram to which these requirements apply
July 1, 2020effective date examples repeated
J/Q/CPT/HCPCS
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code systems represented
Coverage Criteria and Requirements
Drug/Oncology prior authorization group
Covered when prior authorization is obtained as specified for the code and diagnosis grouping.
Oncology drug codes requiring prior auth: For J- and Q-coded, provider-administered oncology and injectable medications listed in this document, prior authorization is required when used with Oncology DX Codes; some codes have effective dates and may require PA regardless of diagnosis as indicated in the list.
Providers must follow per-code effective dates shown in the listing and submit requests via the payer portal as directed.
Procedure/device prior authorization group
Covered when prior authorization is obtained for specified procedure/device CPT codes.
Surgical and device codes: Specific CPT procedure and device codes (examples: bariatric surgery 43644/43645; bone growth stimulator 20975/20979; cardiology device codes listed such as 33274, 33270, 33221/33225/33228) require prior authorization per the code-level listing; some entries include diagnosis restrictions and per-code effective dates.
See the code list for individual effective dates and submission instructions on the Provider Portal.
General PA mapping
Prior authorization entries present; specific clinical criteria not provided in these chunks.
PA mapping: The table maps specific J-code subcategories to diagnosis codes (for example J9177/J9246 mapped to diagnosis J9198/J9358) and records a prior authorization effective date (e.g., July 1, 2020). Detailed clinical medical necessity criteria are not included in the provided extracts.
Use the listed code/diagnosis pairings and effective dates to determine whether PA is required; follow payer portal submission process.
General prior authorization requirement (code list)
Prior authorization required for listed codes and subcategories when billed under Texas STAR.
Code-level requirement: Prior authorization is required for the specific HCPCS/CPT/HCPCS subcategory codes enumerated in this section (examples include enteral/home nutrition codes B4034/B4035 effective May 1, 2019; genetic/molecular testing CPT codes with PA requirements; numerous injectable medications with listed effective dates). Where an effective date is provided, PA is required starting that date.
No detailed clinical necessity criteria are included in these chunks; refer to per-code rows for effective dates and portal submission instructions.
Prior authorization is not required for emergency or urgent care. This policy excerpt explicitly exempts services provided in emergency or urgent care settings from prior authorization requirements; however, routine prior authorization rules apply for non-emergent care and site-of-service conditions described elsewhere in the listing. Providers should continue to submit non-emergent prior authorization requests via the UnitedHealthcare Provider Portal or chat per the instructions in the policy cover page.
Some colony-stimulating and other cancer supportive care codes (examples listed as Q5136, Q5158, J1449 and related codes) do not require prior authorization when used with non-oncology diagnoses. The document states these codes require prior authorization only when billed with Oncology DX Codes and are not subject to prior authorization for other diagnoses; effective dates for these entries are shown inline in the table (e.g., Apr. 1, 2026 / Oct. 1, 2023). Providers must follow the payer submission process when prior authorization is required.
The extracted fragments in this section do not include explicit clinical coverage criteria or listed clinical exclusions. The table rows show code and subcategory mappings (for example, repeated entries referencing Q5119/J9246/J0642 and associated diagnosis codes) but the provided text does not contain medical necessity language, indication-specific clinical rules, or stepwise criteria for authorization decisions.
Within the visible excerpts there are no explicit exclusions documented. The rows shown enumerate code groups and effective dates (for example J9177/J9246 with an effective date of July 1, 2020) but do not list exclusionary conditions or service denials in the extracted text.
This partial extract does not state any explicit exclusions. It lists repeated code/subcategory entries (for example Subcategory = J9246, Code = J9246, Diagnosis code = J9358) and shows prior authorization fields, but no exclusionary language appears in the supplied fragments.
The visible portion of the table does not include explicit exclusions. It documents code-level rows (e.g., J9246 with diagnosis J9358) and empty or unpopulated prior authorization fields in this extract, but no exclusion statements are present in the text shown.
Several codes in the listing are labeled Investigational/Experimental or Potentially Unproven in the extract (examples include 33477, 36514, 66180 marked Investigational/Experimental and 33289, C2624 noted as Potentially Unproven). These labels indicate those specific services may not be routinely covered and may have a different coverage stance than the general prior authorization listings.
The document identifies certain items as Potentially Unproven (for example 33289, C2624) which suggests these codes may be subject to a different coverage determination or may require additional review beyond standard prior authorization. The extract does not provide the detailed coverage stance or medical necessity criteria for these items.
At least one entry explicitly states "Prior authorization is not required" for a listed line: the summary and table fragments note that for some codes (notably supportive care/cytokine agents when not used with Oncology DX Codes) and in one additional information field the text reads "Prior authorization is not required". Providers should confirm per-code rules in the full policy before submission.
No statements of not medically necessary are present in the provided chunks. The excerpts contain code listings, effective dates, and administrative notes but do not include any explicit "not medically necessary" determinations in the visible text.
Code Listings and Coding Notes
Durable Medical Equipment HCPCS (sample)HCPCSCovered
E2512
Wheelchair accessory
E0766
Powered positioning device
E0466
Complex ventilator
A9279
Unclassified DME supply
E0194
Breast pump, hospital grade
E0265
Bed accessory
E0300
Electric bed
E0445
Respiratory interface
E0457
Respiratory tubing
E0638
Compression device
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What Providers Must Do
Prior Authorization
Prior Authorization Required
Prior authorization is required for many provider-administered drugs, chemotherapy J‑codes, Q5119/J9358 entries, and numerous CPT/HCPCS codes listed in this section. Providers must follow the payer's prior authorization process and submit requests through the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (One Healthcare ID portal) or by phone/chat where available. Prior authorization is not required for emergency or urgent care. Out-of-network authorization requests must be initiated by a network care provider.
Provider-administered drugs (many HCPCS J-/Q-codes) require prior authorization — see injectable medications list and chemotherapy J-code groups.
Q5119 / J9358 and related entries: multiple listings indicate Prior Authorization effective dates (e.g., March 1, 2020; July 1, 2020) and require PA for those code/diagnosis pairings.
Chemotherapy J-codes (many J‑codes listed throughout the Chemotherapy section) require prior authorization with various effective dates (examples: J9309 effective Feb. 1, 2020; others noted with 2019–2023 dates).
Numerous CPT and HCPCS codes (e.g., rhinoplasty CPT 30400/30410 with PA effective Jan. 1, 2015; therapy codes; DME/orthotics/prosthetics with retail purchase or cumulative rental cost thresholds) require prior authorization.
Site-of-Service (SOS) notes: Prior authorization for some procedures is required only when requesting service in an outpatient hospital — verify SOS requirement before submitting.
Site-of-Care Notes and Applicability
Note
Note
Note
Policy Background and Scope
This section of the source is primarily an administrative prior authorization list for the Texas STAR program and does not provide clinical rationale or detailed medical necessity criteria. It enumerates code-level prior authorization requirements, effective dates, and submission instructions (submit via the UnitedHealthcare Provider Portal using One Healthcare ID or via 24/7 chat). Where clinical restrictions are implied (for example, oncology diagnosis dependencies), the document references diagnosis groupings such as Oncology DX Codes but does not include the underlying clinical decision rules in the extracted text.
Definitions and Key Terms
Oncology DX Codes
Oncology diagnosis codes referencedEntries reference 'Oncology DX Codes' as the applicable diagnosis grouping for many J- and Q-coded oncology medications.
ImplicationPrior authorization for many J/Q codes is contingent on the associated oncology diagnosis codes listed in the table.
Provider actionWhen submitting PA for oncology J/Q codes, include the applicable Oncology DX Code(s) as documented in the table.
Referenced diagnosis/code pair
Referenced diagnosis/code pairing exampleTable entries repeatedly pair HCPCS code J9358 with diagnosis codes such as J9198 in the listing excerpt.
ImplicationAuthorization requirements for J9358 are shown in code/diagnosis pairings; providers must submit the matching diagnosis with the PA request.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior authorization requirements — Texas STAR (codes and submission instructions)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateApr 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (One Healthcare ID) or use 24/7 chat as directed on the Contact us page.
Therapy and outpatient therapy codes (examples: S9152, 70371, 92626, 97139, 97150) are subject to prior authorization per listed effective dates.
Genetic/molecular testing: prior authorization/notification required for genetic testing performed in outpatient settings; ordering provider must complete prior auth/notification and indicate laboratory and test name.
Circumcision: prior authorization entries list a contact number for some rows (example: 397‑8129) — follow listed contact info when present.
Launch-review / Review at Launch medications: newly launched or market drugs may be flagged for review at launch; pre-determination is highly recommended and providers should consult the Review at Launch Medication List and policies on UHCprovider.com.
Documentation fields and Additional information/How to obtain prior authorization fields: many table rows include these fields but are frequently blank or contain only dates. When present, follow the specific instructions in those fields.
Potential denial risk: absence of required prior authorization may result in claim denial for listed codes and medications; providers should obtain PA before services are rendered when required.
No explicit step-therapy requirements are specified in these extracted rows; the document does not list step therapy rules here.
How to obtain prior authorization: primary channels — UnitedHealthcare Provider Portal (Prior Authorization and Notification tool via One Healthcare ID), phone numbers or portal chat where provided; when the Additional information field is blank, use the Provider Portal or contact the plan for guidance.
PA submission details: some rows reference an "Additional information/How to obtain prior authorization" field but detailed procedural steps are not included in this extract — providers must use the Provider Portal and the payer contact resources.
Documentation: retain and submit required clinical documentation as requested by the payer; many code rows include empty documentation fields — be prepared to supply clinical rationale, diagnosis codes, and laboratory or prior testing information when requested.
Denial risk for unlisted authorization: services or drugs included on the Review at Launch list or otherwise marked for prior authorization without completed PA/notification may be denied if not pre-authorized.
Denial Risk
Denial Risk if PA Missing
Failure to obtain prior authorization when required can lead to claim denial. This is particularly noted for chemotherapy and high-cost injectable medications (multiple J/Q-code entries reference explicit PA effective dates). Verify PA requirements and effective dates for each code before delivering services.
Claims for listed J‑codes (examples: J9246, J9358, J9177, J0642, Q5119) without prior authorization for the specified diagnosis pairings may be denied.
Date‑specific authorization requirement: many entries list effective dates (e.g., Oct. 1, 2020; July 1, 2020; March 1, 2020) — claims for services on/after those dates require PA.
Outpatient vs inpatient distinctions: some entries state PA is required for inpatient services but not for outpatient (or vice versa) — follow the line-item notes for site-of-service exceptions.
Documentation Required
Documentation & How to Obtain Prior Authorization
When the table's "Additional information/How to obtain prior authorization" or documentation fields are blank, providers should still submit requests via the Provider Portal and include complete clinical documentation. For genetic/molecular testing and certain specialty drugs, the ordering provider must indicate the laboratory and test name as part of the prior authorization/notification process.
Use UHCprovider.com > Menu > Policies & Authorization > Medical & Pharmacy Policies or the Review at Launch Medication List for up‑to‑date directions on new-to-market drugs.
For genetic testing: complete the prior authorization/notification process including laboratory and test name; payment authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program.
Documentation fields in the table may be empty — include supporting notes, diagnosis codes, prior therapies/tests, and the laboratory/test identifiers where applicable.
Billing Rule
Billing Rules & Site‑of‑Service Notes
If a procedure or drug is listed with site‑of‑service limitations, or with cost or modifier conditions (for example DME retail purchase/cumulative rental > $500, dental anesthesia modifier U3 for members <21), follow those specific billing rules when requesting authorization.
DME/prosthetics: PA required for retail purchases or cumulative rental cost thresholds (commonly > $500) — check each code's Additional information field.
Dental anesthesia: PA required for members younger than 21 when billed with Modifier U3.
Site-of-service (SOS) outpatient hospital: PA only required when requesting service in an outpatient hospital setting for specific codes (see SOS entries).
Note
Launch‑Review Flagged Medications
For drugs on the Review at Launch list or otherwise flagged as new-to-market, pre-determination is highly recommended. Providers should consult the Review at Launch Medication List and related policies for submission and review expectations.
Review at Launch medications — pre-determination encouraged; consult UHCprovider.com > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.
Launch flags: some injectable medications are marked "Launch for New to Market" — authorization pathways and requirements may change as policies are updated.
Contact Optum SGP or plan-specified vendor where indicated (examples: Optum SGP for certain specialty products).
Provider actionVerify and include the specific diagnosis code (e.g., J9198 or J9358 as shown) when requesting prior authorization for the associated J-code.
J9246 / J9358 / Q5119
Referenced code groupingJ9246, J9358 and modifier Q5119 are referenced together multiple times in the table as a grouped set of codes.
ImplicationThese codes appear in repeated PA rows indicating specific handling or diagnosis linkage in the prior authorization listing.
Provider actionWhen these codes appear together on a claim or PA request, follow the table's PA requirements and include the linked diagnosis codes.
Genetic and Molecular Testing Prior Authorization/Notification program
Genetic and Molecular Testing programGenetic and molecular testing performed in an outpatient setting requires prior authorization/notification and payment will be authorized for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification program.
Provider requirementOrdering providers must complete the prior authorization/notification process and indicate the laboratory and test name; registered labs/CPTs are authorized.
Effective datesSome genetic testing entries include effective dates (example: Dec. 1, 2022 for certain genetic testing entries).