Authorization and Notification Requirements - UCare Individual & Family Plans (IFP)
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Defines UCare prior authorization and notification requirements for inpatient, outpatient, DME, procedures, genetic testing, and other services for UCare Individual & Family Plans (IFP) and IFP with M Health Fairview. Affects providers submitting requests for covered members under these plans.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
General medical necessity approach
Services require prior authorization when listed and must meet InterQual or other specified medical necessity criteria:
Applies across listed services; see specific service for codes and procedure-level notes
Service-specific criteria examples
Examples of service-specific requirements:
EAS-enrolled providers may have different notification requirements for some inpatient admissions.
Some emergency procedures (e.g., emergency surgery for trauma) are excluded from PA requirement per specific sections.
UCare reserves the right to determine rental versus purchase and will use the appropriate InterQual DME subset for medical necessity determinations; refer to Carelon portal for genetic testing after delegation date.
Wheelchair purchase/rental/accessory coverage criteria
Covered when prior authorization and InterQual medical necessity criteria are met
Use InterQual Medicare Durable Medical Equipment or InterQual Care Plan (CP) Durable Medical Equipment appropriate subset for medical necessity determinations.
UCare reserves the right to determine rental vs. purchase; repair or replacement of rental equipment is the provider's responsibility.
See Wheelchair Accessories section for accessory purchase, repair and replacement authorization requirements.
Vein procedures
Procedures listed require prior authorization
Refer to InterQual Care Plan (CP) Procedures (Ablation, Endovenous Varicose Vein; Ambulatory Phlebectomy; Sclerotherapy) for medical necessity details.
Authorization is not required for breast reconstruction associated with breast cancer. For other cosmetic and reconstructive procedures listed, prior authorization is required prior to service; see the cosmetic procedures section for examples and codes. Photographs are not routinely required when requesting authorization for cosmetic or reconstructive surgeries, but a Utilization Review Specialist may request them if needed.
No additional exclusions or non-covered items are explicitly listed in this document portion for the wheelchair accessories and related DME sections.
No additional not-medically-necessary determinations are specified in this document portion.
Codes and Billing Thresholds
| InterQual CP Procedures | Ablation, Endovenous Varicose Vein; Ambulatory Phlebectomy, Varicose Veins; Sclerotherapy, Varicose Veins |
| E0986 | HCPCS wheelchair accessory/equipment code listed |
| E1002 | HCPCS wheelchair accessory/equipment code listed |
| E1003 | HCPCS wheelchair accessory/equipment code listed |
| E1004 | HCPCS wheelchair accessory/equipment code listed |
| E1005 | HCPCS wheelchair accessory/equipment code listed |
| E1006 | HCPCS wheelchair accessory/equipment code listed |
| E1007 | HCPCS wheelchair accessory/equipment code listed |
| E1008 | HCPCS wheelchair accessory/equipment code listed |
| E1009 | HCPCS wheelchair accessory/equipment code listed |
| E1010 | HCPCS wheelchair accessory/equipment code listed |
| K0800 | Power wheelchair rental code listed |
| K0801 | Power wheelchair rental code listed |
| K0802 | Power wheelchair rental code listed |
| K0806 | Power wheelchair rental code listed |
| K0807 | Power wheelchair rental code listed |
| K0808 | Power wheelchair rental code listed |
| K0812 | Power wheelchair rental code listed |
| K0813 | Power wheelchair rental code listed |
| K0814 | Power wheelchair rental code listed |
| K0815 | Power wheelchair rental code listed |
Provider Requirements, Submission, and Denial Risks
Obtain prior authorization before listed services
Prior authorization must be obtained prior to service or delivery for the procedures, DME, genetic/molecular tests, cosmetic procedures, spine surgeries, prostheses, sleep studies, spinal cord stimulation, TMS, proton beam therapy, transplants, and specified wheelchair purchases and accessories as listed in each section.
- Refer to each section’s code list to confirm which services require PA prior to provision.
- Genetic testing is delegated to Carelon as of 7/1/25 — follow Carelon portal instructions for authorization after that date.
Authorize wheelchair equipment and accessories before delivery
Prior authorization is required before delivering, dispensing, purchasing, renting, repairing or replacing wheelchair-related accessories or equipment listed by code; all months of rental must be authorized.
Obtain prior authorization for listed vein procedures
Prior authorization is required prior to service for the listed vein procedures including ablation, endovenous varicose vein procedures, ambulatory phlebectomy, and sclerotherapy.
Drug prior authorization for medical injectable drugs
Medical injectable drugs included in the Medical Drug Policy library require prior authorization; the formulary determines which drugs are covered under the pharmacy benefit.
- Follow the Medical Drug Policy library for PA requirements and the plan formulary for pharmacy coverage determinations.
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Submit authorization/notification request with supporting documentation
To request prior authorization or to provide required notification, complete the appropriate UCare authorization/notification request form and submit it with supporting clinical documentation by fax or email as directed on the form.
- Providers may request a copy of the criteria used for medical necessity determinations on UCare's Authorization page.
- Include relevant clinical records per the form instructions to support the PA request.
Notify UCare for inpatient admissions and submit discharge summary
For inpatient admissions that require notification, notify UCare within the required timeframe (typically within 24 hours of admission if not enrolled in EAS) and send the discharge summary within 72 hours of discharge.
- Fax numbers for Acute Inpatient Medical and Inpatient Mental Health Admissions are provided in the policy for submission.
- Concurrent review is required for additional inpatient days as noted per service type.
Use InterQual DME criteria for wheelchair medical necessity
Medical necessity for wheelchair purchase, rental, and accessories will be determined using InterQual Medicare Durable Medical Equipment or the InterQual Care Plan (CP) Durable Medical Equipment appropriate subset based on the requested item.
- UCare or its authorizing delegate will choose the appropriate InterQual subset when reviewing DME/wheelchair PA requests.
Risk of claim denial if authorization not obtained
Failing to obtain prior authorization in advance for services that require authorization may result in a denied claim.
Denial triggers for wheelchair/DME without authorization
Failure to obtain prior authorization for wheelchair accessories, purchases (e.g., K0005–K0007, E1161), all power-operated vehicles and power wheelchairs, rentals (listed K08xx codes), or miscellaneous codes K0108/K0669 when billed charges exceed $1,500 may trigger a denial.
- All months of rental must be authorized; repair/replacement of rental equipment is provider responsibility and still requires PA where applicable.
Vein procedures may be denied without prior authorization
Procedures for veins listed under authorization requirements (ablation, endovenous varicose vein procedures, ambulatory phlebectomy, sclerotherapy) require prior authorization; performing these procedures without PA may result in denial.
Background and Standards
InterQual criteria sets are the referenced medical necessity standard for authorization determinations. Appropriate InterQual subsets (for example, Level of Care, Medicare Procedures, Care Plan Procedures, or Behavioral Health Procedures) will be chosen based on the requested service to determine medical necessity for prior authorization decisions.
Key Definitions
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