Prior Authorization Required — Denial Risk

Prior authorization is required prior to many procedures and services listed in this section. Failing to obtain required prior authorization in advance may result in a denied claim. Allow up to seven calendar days for a non-urgent authorization decision. All services remain subject to member eligibility and benefit coverage.

• Providers may request the criteria used for a medical necessity determination on UCare's Authorization page
• Not all plans offer out-of-network benefits; contact UCare Provider Assistance Center at 612-676-3300 or 1-888-531-1493 for eligibility, benefits, and network questions

Visit/Session/Unit Thresholds — Prior Authorization

Some services have visit, session, unit, or day thresholds. Prior authorization is required when those thresholds are exceeded. Examples below indicate common thresholds; always verify with the specific service entry for exact limits.

• Physical Therapy — prior authorization required after 14 visits per calendar year
• Occupational Therapy — prior authorization required after 24 visits per calendar year
• Psychotherapy (Individual) — threshold limit of 52 visits per year; prior authorization required for additional visits
• Psychotherapy (Group) — threshold limit of 52 visits per year; prior authorization required for additional visits
• Partial Hospitalization Program — treatment exceeding 21 calendar days following admission requires authorization
• Adult Residential Crisis Stabilization Services — treatment exceeding 10 days in a calendar month requires authorization
• H0034 (rehabilitation units) — authorization required for more than 26 hours / 104 units per calendar year
• 90882 (psychotherapy) — authorization required for more than 72 sessions per calendar year
• SUD Outpatient Treatment — treatment exceeding six hours per day or thirty hours per week requires prior authorization (hours calculated in a rolling seven-day span)
• Substance Use Disorder Outpatient Treatment authorizations can be given for up to a 28-day time span

Prior Authorization Required — Service Examples

UCare requires prior authorization prior to delivery, purchase, or performance of many high-cost or specialized services. This includes, but is not limited to, DME items that require authorization (E1399 when billed charges exceed $1,500), power-operated vehicles and power wheelchairs (purchase and rental), artificial disc replacement, bariatric surgery, cranial nerve stimulation, spinal cord stimulation (trial and permanent placement), proton beam therapy, TMS, transplant evaluation and listing, orthognathic surgery, and EIDBI services.

• Durable Medical Equipment (DME) — prior authorization required prior to delivery or dispensing of items that require authorization; miscellaneous code E1399 requires authorization if billed charges exceed $1,500
• Wheelchair purchase/rental — prior authorization required prior to purchase for K0005–K0007, E1161, all power-operated vehicles and power wheelchairs; prior authorization required prior to delivery/dispensing for rental months and delivery
• Artificial Disc Replacement (CPT 22856, 22857, 22858) — prior authorization required prior to service
• Bariatric Surgery (CPT 43644, 43645, 43770, 43773, 43775, 43842, 43845–43848) — prior authorization required prior to service
• Cranial Nerve Stimulation (CPT 64553, 64568, 64569, 64582) — prior authorization required prior to service; route requests involving mental health diagnoses to the Mental Health and Substance Use Disorders fax line
• Spinal Cord Stimulation (CPT 63650, 63655, 63663, 63664, 63685) — prior authorization required prior to trial and permanent placement
• Proton Beam Therapy (CPT 77520, 77522, 77523, 77525) — prior authorization required prior to service
• Transcranial Magnetic Stimulation (CPT 90867, 90868, 90869) — prior authorization required prior to service
• Transplant — prior authorization required prior to evaluation and listing; notification required within 24 hours of admission for transplant procedures
• Early Intensive Developmental and Behavioral Intervention (EIDBI) — prior authorization required prior to service
• Orthognathic Surgery (CPT 21121, 21141–21147, 21193–21198, 21249, 21255–21296, 30120, 30400–30450, 30540–30560, 30620, 40500, 67900, 67912, 69090, 69300, 69320) — prior authorization required prior to service

Inpatient Notification, Concurrent Review, and Documentation

For inpatient and facility-based admissions where notification or concurrent review is required, providers should follow the stated notification timelines and submit required documentation (for example, discharge summaries). Failure to notify or obtain authorization when required may lead to claim denial.

• Acute Inpatient Hospitalization (medical, mental health, SUD) — concurrent review required when applicable; discharge summary required upon discharge; notification within 24 hours if not enrolled in UCare EAS
• Neonatal Intensive Care Unit (NICU) — authorization required for Levels II–IV; notification within 24 hours of admission; concurrent review required for additional days; discharge summary required upon discharge
• Long-Term Acute Care (LTAC) — discharge summary required upon discharge; concurrent review for additional days
• Psychiatric Residential Treatment Facilities (PRTF) — prior authorization required prior to admission; concurrent review required for additional days; discharge summary required to be sent

Clinical Criteria and Documentation Expectations

UCare applies InterQual and Minnesota Health Care Programs Provider Manual criteria where applicable to determine medical necessity for many services and DME. Providers should be prepared to submit clinical documentation that supports the requested service according to the referenced criteria.

• DME and wheelchairs — InterQual DME criteria and Minnesota Health Care Programs Provider Manual criteria will be applied
• Rehabilitation services (PT/OT/SLP) — InterQual LOC Rehabilitation subsets will be used based on procedure code
• Behavioral health services (TMS, VNS, SUD) — InterQual BH criteria or ASAM criteria will be applied as specified