Acute Inpatient Rehabilitation - Prior Authorization

Prior authorization is required prior to admission for acute inpatient rehabilitation; concurrent review required for additional days.

Air Ambulance (Non-Emergent) PA

Prior authorization required for non-emergent fixed-wing air ambulance transport. Authorization is not required for emergent air transport.

• Affected codes: A0430, A0435

Artificial Disc Replacement PA

Artificial disc replacement procedures require prior authorization prior to service.

• Affected codes: 22856, 22857, 22858

Back (Spine) Surgery - PA

Prior authorization is required for specified lumbar spinal fusion, sacroiliac joint fusion, and related spine procedures prior to service (authorization not required for specified emergent or excluded indications).

• Examples of affected codes: 22533, 22534, 22558, 22612, 22614, 22630, 22632, 22633, 22634, 22808, 22810, 22812, 22840, 22841, 22842, 22843, 22844, 27279, 27280, 64628, 64629

Bariatric Surgery PA

Prior authorization is required prior to bariatric (gastric bypass) surgery.

• Examples of affected codes: 43644, 43645, 43770, 43773, 43775, 43842, 43845, 43846, 43847, 43848

Children's Therapeutic/Residential Services PA

Authorization required when Children's Therapeutic Services and Supports (CTSS) services exceed 200 cumulative hours in a calendar year; prior authorization required prior to admission for Children's Residential Treatment, concurrent review required for additional days, and discharge summary required upon discharge.

• CTSS affected codes include H2014, H2015, H2019, H0031, H0032 and psychotherapy codes as listed in policy
• Children's Residential Treatment affected code: H0019

Durable Medical Equipment PA

Prior authorization required prior to delivery/dispensing of DME items that require authorization. UCare reserves the right to determine rental vs. purchase; repair or replacement of rental equipment is the provider's responsibility. Miscellaneous HCPCS E1399 requires authorization if billed charges exceed $1,500.

• Examples of DME codes that may require authorization: E0483, E0652, E0748, E0749, E0766, E1399
• UCare may apply InterQual DME criteria to determine medical necessity and rental vs. purchase

EIDBI PA

Prior authorization required prior to Early Intensive Developmental and Behavioral Intervention (EIDBI) services.

• Affected codes include 0373T UB, 97153 UB, 97154 UB, 97155 UB, 97156 UB, 97157 UB

Formula/Nutritional Services PA

Prior authorization required for formula and nutritional services except when administered through a feeding tube (no authorization required if tube-administered).

• Affected HCPCS/NDC codes include B4102, B4103, B4105, B4149–B4162
• Authorization required prior to service unless administered via feeding tube

Home Care Nursing Prior Authorization

Prior authorization required prior to the first visit for Home Care Nursing (formerly Private Duty Nursing).

• Affected codes: T1002, T1003

ARMHS Threshold-Based Authorization

Prior authorization required for treatment exceeding specified ARMHS calendar year thresholds.

• Authorization required for more than 300 hours / 1200 units per calendar year
• 90882 requires authorization for more than 72 sessions per calendar year
• H0034 requires authorization for more than 26 hours / 104 units per calendar year
• Add HM, HQ, U3 or U3 HM modifiers as appropriate

Specialized Therapy Prior Authorization (examples)

Prior authorization required prior to service for Proton Beam Therapy, Transcranial Magnetic Stimulation (TMS), spinal cord stimulation (trial and permanent), and other high-cost or specialized therapies as listed in the policy.

• Proton Beam Therapy example codes: 77520, 77522, 77523, 77525
• TMS codes: 90867, 90868, 90869
• SCS trial/permanent codes: 63650, 63655, 63663, 63664, 63685

Facility-Based Sleep Study Prior Authorization

Facility-based sleep studies require prior authorization prior to service.

• Affected CPT codes: 95807, 95808, 95810, 95811
• Medical necessity criteria: InterQual Care Plan (CP) Procedures: Sleep Studies

Wheelchair Accessory Authorization

Wheelchair accessories with billed charges over $1,500 (for K0108 and K0669) and other accessories/items that require authorization must be authorized prior to delivery or dispensing. Prior authorization is also required prior to purchase for specified wheelchair purchase codes and for all power-operated vehicles and power wheelchairs.

• Wheelchair accessory HCPCS examples: E0986, E1002–E1012, E1030, E2204, E2227–E2331, E2376, E2609, E2617; K0108, K0669
• Accessory authorization threshold: billed charges > $1,500 for K0108 and K0669
• Wheelchair purchase codes requiring prior authorization: K0005–K0007, E1161, and all power-operated vehicles/power wheelchairs
• UCare reserves the right to determine rental vs. purchase

Submission and Documentation

Complete the appropriate prior authorization or notification request form with supporting clinical documentation as needed and submit by fax or email to UCare according to the return information on each form. Providers may request a copy of the criteria used in a medical necessity determination via UCare's Authorization page.

• Allow up to seven calendar days for non-urgent authorization decisions
• Failing to obtain required prior authorization in advance may result in a denied claim
• UCare does not review predetermination requests
• Contact the UCare Provider Assistance Center for eligibility, benefits and network status questions

Discharge Summary Requirement

Discharge summaries are required to be sent upon discharge for inpatient admissions where noted (examples: acute inpatient hospitalization, inpatient rehabilitation, LTAC, NICU, IRTS, psychiatric residential treatment, skilled nursing facility admissions, and inpatient substance use disorder admissions). For general inpatient hospital notifications, discharge summary must be sent within 72 hours of discharge when required.

• Send discharge summaries within 72 hours for inpatient hospital and substance use disorder admissions when specified
• Discharge summary required upon discharge for: Acute Inpatient Hospitalization, Acute Inpatient Rehabilitation, Long-Term Acute Care (LTAC), NICU, Children's Residential Treatment, IRTS (when >90 days or as specified), Psychiatric Residential Treatment Facilities (PRTF), Skilled Nursing Facility (SNF) admissions

Admission Notification and Concurrent Review

Providers must notify UCare within required timeframes for certain admissions and initiate concurrent review when additional inpatient days are anticipated or required. Notification/authorization timeframes vary by setting.

• Notification required within 24 hours of admission for NICU (Levels II-IV), inpatient hospital admissions if not enrolled in UCare EAS, transplant procedures, and inpatient substance use disorder admissions
• Concurrent review is required for additional days for acute inpatient hospitalization, inpatient rehabilitation, LTAC, NICU, nursing facility admissions, psychiatric residential treatment, and other inpatient settings as specified
• Failure to notify or obtain required authorization or concurrent review may result in denial risk

IRTS Prior Authorization for Extended Stays

For Intensive Residential Treatment Services (IRTS), treatment exceeding 90 days requires authorization; readmission within 15 days counts toward the 90-day total. Discharge summaries and concurrent review apply as noted in the policy.

• IRTS code example: H0019
• Readmission within 15 days counts toward the 90-day treatment total

Denial Risk for Missing Prior Authorization / Concurrent Review

Failure to obtain required prior authorization in advance, or to comply with required notifications and concurrent review processes, may result in denied claims or payment denials.

Rental vs. Purchase Determination

UCare reserves the right to determine rental vs. purchase; appropriate InterQual DME criteria and medical necessity guidelines will be applied based on the requested item. Repair or replacement of rental equipment is the provider's responsibility.

• Used in decisions for wheelchairs, power-operated vehicles, and other DME
• Providers should obtain authorization prior to purchase for listed K-codes and power wheelchairs to avoid denial