CurrentUCarePolicy N/A

prior_authorization_and_notification_requirements

Lists services that require prior authorization or notification for UCare plans (inpatient/outpatient), including CPT/HCPCS code lists, program applicability (UCare Connect, MSC+, PMAP, MinnesotaCare), documentation requirements, and referenced medical necessity criteria sources. This is Part 1 of 2.

Policy Summary

PayerUCare

Policyprior_authorization_and_notification_requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization prior to services specified (see service-specific entries) and submit appropriate request forms with supporting clinical documentation by fax or email as noted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief (has_material_change=false).

30+Services listed in Part 1

MultipleCPT/HCPCS codes enumerated

Contact listService Contacts Provided

Coverage Summary (Part 1)

UCare requires prior authorization or notification for many inpatient and outpatient services; determinations rely on referenced medical necessity criteria sources. This document is Part 1 of 2 and lists services, CPT/HCPCS codes, program applicability, documentation requirements, and referenced criteria.

Authorization or notification is required as specified, but PA does not guarantee payment; providers should follow the listed requirements and submission instructions.

Key Authorization Thresholds

ARMHS (H2017)> 300 hours / 1200 units per calendar year

ARMHS (90882)> 72 sessions per calendar year

ARMHS (H0034)> 26 hours / 104 units per calendar year

Adult Residential Crisis Stabilization (H0018)> 10 days in a calendar month

Intensive Residential Treatment Services (IRTS) (H0019)> 90 days (readmission within 15 days counts toward total)

Substance Use Disorder Outpatient (H2035)> 6 hours per day or > 30 hours per week (hours calculated in a rolling 7-day span)

UCare requires prior authorization or notification for many inpatient and outpatient services; medical necessity determinations rely on InterQual and the Minnesota Health Care Programs Provider Manual criteria where indicated. To provide prior authorization or notification, complete the appropriate request form with supporting clinical documentation and submit by fax or email as noted on each form. Authorization does not guarantee payment.

Authorization & Medical Necessity Criteria

General Authorization/Notification Rules

UCare requires providers obtain prior authorization or provide notification as specified; failure to obtain required prior authorization may result in denied claims. Submit appropriate request forms with supporting clinical documentation by fax or email as noted on each form.

Timeframe for non-urgent decisions: Allow up to 14 calendar days for a non-urgent authorization decision
Eligibility and coverage: All services subject to member eligibility and benefit coverage
Failure to obtain authorization: For services that require authorization, failing to obtain the authorization in advance may result in a denied claim
Predeterminations excluded plans: UCare does not review predeterminations for UCare Connect, MSC+, PMAP and MinnesotaCare at this time
How to submit a PA or notification: To provide PA or notification, complete the appropriate request form with supporting clinical documentation and submit by fax or email as noted on each form
Contact Medical Services Authorizations page or listed phone/fax for submission details

Provider contacts: Obtain medical authorizations via Medical Services Authorizations phone or fax; contact Mental Health and Substance Use Disorder Services for behavioral health auths

See contact information for phone/fax details

Notification-only requirements

Notification required as specified; timing and discharge summary requirements apply.

Inpatient notifications

Acute Inpatient Medical Admissions: If enrolled with UCare Encounter Alert System (EAS), notification not required; if not enrolled, notification within 24 hours of admission; discharge summary within 72 hours of discharge
Fax: Acute Inpatient Medical Admissions to 612-884-2499 or 1-866-610-7215
Inpatient Mental Health Admissions: If enrolled with EAS, notification not required; if not enrolled, notification within 24 hours of admission; discharge summary within 72 hours
Fax: Inpatient Mental Health Admissions to 612-884-2033 or 1-855-260-9710
Inpatient Substance Use Disorder Admission: Notification within 24 hours of admission; discharge summary within 72 hours
Fax: 612-884-2033 or 1-855-260-9710

Authorization-required services (selected entries from Part 1)

Services that require prior authorization prior to service unless exceptions noted; some have concurrent review or notification timing requirements and reference InterQual and Minnesota Health Care Programs Provider Manual criteria where indicated.

Acute Inpatient Rehabilitation: Notification required within 24 hours of admission; concurrent review required for additional days; discharge summary required upon discharge

Medical necessity criteria: InterQual LOC Rehabilitation; appropriate subset chosen based on reason for admission

Adult Rehabilitative Mental Health Services (ARMHS): Prior authorization required when treatment exceeds calendar year thresholds

CPT/HCPCS: H2017 - authorization required for >300 hours/1200 units per calendar year; 90882 - authorization required for >72 sessions per calendar year; H0034 - authorization required for >26 hours/104 units per calendar year; add HM/HQ/U3 modifiers as appropriate; Medical necessity: Minnesota Health Care Programs Provider Manual: Mental Health Services, ARMHS

Adult Residential Crisis Stabilization Services: Treatment exceeding 10 days in a calendar month requires authorization

Durable Medical Equipment determination

Policy statements regarding wheelchair and DME determinations and applicable medical necessity criteria.

Rental vs Purchase determination: UCare reserves the right to determine rental vs. purchase for wheelchairs and other DME; repair or replacement of rental equipment is the provider's responsibility

All months for wheelchair rentals must be authorized when applicable

InterQual DME criteria: Medical necessity criteria for durable medical equipment (including wheelchairs and accessories) will follow InterQual Care Plan (CP): Durable Medical Equipment appropriate subset chosen based on the requested item

Minnesota Health Care Programs Provider Manual: Equipment and Supplies will also be used to choose appropriate coverage criteria

Code Lists and Status

Notification fax numbers by admission typemixed

Acute Inpatient Medical Admissions fax	612-884-2499 or 1-866-610-7215
Inpatient Mental Health / Inpatient Substance Use Disorder fax	612-884-2033 or 1-855-260-9710

ARMHS and Behavioral Health codesCPT|HCPCSCovered

H2017	ARMHS - authorization required for >300 hours/1200 units per calendar year
90882	Authorization required for >72 sessions per calendar year
H0034	Authorization required for >26 hours/104 units per calendar year

Back (Spine) Surgery codesCPTCovered

22533
22534
22558
22585
22586
22612
22614
22630
22632
22633

1–10 of 21

1/3

Bariatric surgery codesCPTCovered

43644
43645
43770
43773
43775
43842
43845
43846
43847
43848

Children's Residential / IRTS codesHCPCSCovered

H0019

Children's Residential Treatment; Intensive Residential Treatment Services

Cosmetic procedure codes (examples list)CPT

11960
15780
15781
15782
15783
15786
15787
15830
15832
15833

1–10 of 74

1/8

Cranial Nerve Stimulation codesCPTCovered

64553
64568
64569
64582

DME example codesHCPCSCovered

E0483	High Frequency Chest Wall Oscillation System
E0652	Pneumatic Compression Device
E0748	Osteogenesis stimulator, electrical, non-invasive, spinal applications
E0749	Osteogenesis stimulator, electrical, surgically implanted
E0766	Electrical Stimulation Device

Genetic / Molecular diagnostics codesCPTCovered

0037U
81162
81163
81164
81165
81166
81167
81210
81212
81215

1–10 of 52

1/6

Proton beam therapy codesCPTCovered

77520
77522
77523
77525

TMS codesCPTCovered

90867
90868
90869

Vein procedure codesCPTCovered

36465
36466
36470
36471
36473
36474
36475
36476
36478
36479

1–10 of 14

1/2

Wheelchair accessory and purchase codesHCPCS|K-codesCovered

E0986
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1009
E1010

1–10 of 35

1/4

Spinal Cord Stimulation codesCPTCovered

63650
63655
63663
63664
63685

Substance use disorder codesHCPCSCovered

H2035	Outpatient Treatment
H2036	Residential Treatment

Home health / Home care codesHCPCSCovered

T1030	SNV
T1031	SNV
T1021	HHA
T1002	Home Care Nursing
T1003	Home Care Nursing

ARMHS modifiersModifier

HM	modifier for ARMHS services as appropriate
HQ	modifier for ARMHS services as appropriate
U3 / U3 HM	modifier variant mentioned

What Providers Must Do

Prior Authorization

Obtain prior authorization when required

Obtain prior authorization when required. Follow the service-specific authorization and notification requirements listed in this policy; complete the appropriate request form and include all required clinical documentation. Submit requests by the fax number or secure email address shown on each form. Failure to follow the service-specific entry (for example, transplant, bariatric, inpatient rehab, DME, or specialty procedures) may delay review or result in denial.

Follow service-specific entries in this policy and related forms
Submit via the fax/email channels noted on each authorization form

Note

Admission notifications

Notify UCare of inpatient admissions and certain other events within the timeframes below. If you are enrolled with the UCare Encounter Alert System (EAS), notification is not required via fax/email; otherwise use the fax numbers listed for the admission type. Send a discharge summary within 72 hours of discharge.

Inpatient hospital admissions: notify within 24 hours if not enrolled with EAS; discharge summary within 72 hours
Inpatient mental health admissions: notify within 24 hours if not enrolled with EAS; discharge summary within 72 hours; fax to 612-884-2033 or 1-855-260-9710
Inpatient substance use disorder residential admissions: notify within 24 hours; discharge summary within 72 hours; special 5-day notification applies for some SUD residential settings per program rules

Denial Risk

Failure to obtain authorization may result in claim denial

Failure to obtain required prior authorization in advance may result in denial of the claim or payment delay.

Claims for services that required prior authorization but were provided without an approved authorization are subject to denial

Documentation Required

Photographs for cosmetic/reconstructive surgery

Photographs for cosmetic or reconstructive surgery are not required with the initial authorization request. If UCare determines photographs are needed for review, the Utilization Review Specialist will request them from the provider.

Cosmetic/reconstructive surgery examples: abdominoplasty, breast reduction, rhinoplasty, panniculectomy, mammoplasty
Photographs: submit only if requested by UCare

Documentation Required

CADI waiver home health notification

For CADI waiver home health notifications, providers must notify UCare per program rules and include applicable service codes on submissions.

Include CADI home health codes where applicable: T1030, T1031, T1021
Notify UCare using the form and contact method specified for waiver/home health services

Documentation Required

UCare rental vs. purchase determinations

UCare reserves the right to determine whether equipment should be rented or purchased based on clinical and cost considerations. Providers should include documentation supporting the recommended rental or purchase option in the authorization request.

UCare may require documentation to support purchase versus rental decisions for DME/medical equipment
Follow DME medical necessity criteria and submission instructions in the DME section

Documentation Required

Follow DME medical necessity criteria

Follow DME medical necessity criteria when requesting authorization for durable medical equipment. Include clinical documentation that demonstrates medical necessity and expected duration of need.

Adhere to DME criteria in this policy and submit supporting documentation with the request

Prior Authorization

Clinical Pharmacy Intake for pharmacy prior authorizations

Clinical Pharmacy Intake handles pharmacy prior authorization requests for medical injectable drugs and related medical drug policies. Use the Clinical Pharmacy Intake phone/fax/email channels and the Medical Authorization form as directed.

Submit medical injectable drug prior authorizations through Clinical Pharmacy Intake per the Medical Drug Policy library instructions
Use the contact channels listed on the Medical Authorization and Medical Drug Policy pages

Prior Authorization

Mental Health and Substance Use Disorder authorizations

Mental Health and Substance Use Disorder (SUD) authorizations require use of the Mental Health and Substance Use Disorder Authorization and Notification Forms and the specified contact channels. Certain behavioral health services also require prior authorization or notification and may have program-specific timeframes.

Use the Mental Health and Substance Use Disorder Authorization and Notification Forms for requests
Inpatient mental health and SUD admissions: follow the 24-hour notification and 72-hour discharge summary requirements
Behavioral health outpatient services (e.g., ARMHS, residential crisis, children's residential treatment) have specific authorization thresholds and CPT/HCPCS guidance as noted in this policy

Allow up to 14 calendar days for non-urgent authorization decisions; urgent requests follow accelerated review timelines.

Background and Definitions

Prior authorization: An approval by an approval authority prior to the delivery of a specific service or treatment; requires clinical review to determine medical necessity and appropriateness. Notification: The process of informing UCare or delegates of a specific medical treatment or service prior to, or within a specified time period after, the start of the treatment or service.

Allow up to 14 calendar days for a non-urgent authorization decision. All services are subject to member eligibility and benefit coverage; failing to obtain required authorization in advance may result in a denied claim. Notification timing and discharge summary requirements (for example, notification within 24 hours of admission and discharge summary within 72 hours where noted) apply as specified for inpatient services.

Policy Summary

PayerUCare

Policyprior_authorization_and_notification_requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Transplants: Step 1: Notification for transplant consult/evaluation; Step 2: Notification for transplant listing; Step 3: Notification within 24 hours of inpatient hospital admissions

>10 days in a calendar month

CPT/HCPCS: H0018; Medical necessity: InterQual BH Adult and Geriatric Psychiatry Residential Crisis Program

Back (Spine) Surgery - Lumbar Spinal Fusion and Sacroiliac Joint Fusion: Prior authorization required prior to service; authorization not required for emergency surgery for trauma, acute transverse myelopathy, tumors, cervical and thoracic back surgery

CPT codes: 22533,22534,22558,22585,22586,22612,22614,22630,22632,22633,22634,22808,22810,22812,22840,22841,22842,22843,22844,27279,27280; Medical necessity: InterQual Medicare Procedures Minimally Invasive SI Joint Fusion; InterQual CP Procedures Lumbar Spinal Fusion; Minnesota Provider Manual: no criteria listed for Lumbar Fusion and SI Joint Fusion

Bariatric Surgery (Gastric Bypass): Prior authorization required prior to service

CPT codes: 43644,43645,43770,43773,43775,43842,43845,43846,43847,43848; Medical necessity: InterQual Procedures Bariatric or Metabolic Surgery; Minnesota Provider Manual: no criteria listed

Children's Residential Treatment: Prior authorization required prior to admission; concurrent review required for additional days; discharge summary required upon discharge

CPT/HCPCS: H0019; Medical necessity: InterQual BH Child and Adolescent Psychiatry - Residential Treatment Center; integrated program applicability noted

Cosmetic Procedures (examples listed): Prior authorization required prior to service; photographs not required unless requested; authorization not required for breast reconstruction associated with breast cancer

CPT codes: examples list including 11960,15780...69320; Medical necessity: InterQual CP Procedures appropriate subset chosen based on requested procedure; Minnesota Provider Manual: Plastic and Reconstructive Surgery

Cranial Nerve Stimulation (Vagus, Hypoglossal): Prior authorization required prior to service; VNS involving mental health diagnosis should be sent to Mental Health and Substance Use Disorders fax line

CPT codes: 64553,64568,64569,64582; Medical necessity: InterQual Medicare Procedures (Hypoglossal Nerve Stimulation, VNS, Peripheral Nerve Stimulation, DBS); InterQual CP/BH Procedures Vagus Nerve Stimulation

Durable Medical Equipment (DME): Prior authorization required prior to delivery or dispensing of DME items that require authorization; UCare reserves right to determine rental vs purchase; repair/replacement of rental equipment is provider's responsibility

Example HCPCS: E0483,E0652,E0748,E0749,E0766; Medical necessity: InterQual CP Durable Medical Equipment; Minnesota Provider Manual: Equipment and Supplies

Early Intensive Developmental and Behavioral Intervention (EIDBI): Prior authorization required prior to service

CPT/HCPCS: 0373T UB,97153 UB,97154 UB,97155 UB,97156 UB,97157 UB; Medical necessity: InterQual BH ABA Program

Genetic or Molecular Diagnostic Tests (cancer-related and panels): Prior authorization required prior to ordering test

CPT codes: 0037U,81162-81167,81210...81551; Medical necessity: InterQual CP Molecular Diagnostics; appropriate subset chosen based on requested testing; Minnesota Provider Manual: Lab/Pathology/Genetic Testing

Home Health Care - Skilled Nurse Visits (SNV) and Home Health Aide (HHA): Notification required prior to the first date of service within a member's CADI waiver approval span; providers must contact member's CADI case manager who must submit DHS-5841-ENG form to UCare

CPT/HCPCS: T1030,T1031 (SNV); T1021 (HHA); integrated program applicability noted

Home Care Nursing (Formerly Private Duty Nursing): Prior authorization required prior to the first visit

CPT/HCPCS: T1002,T1003; Medical necessity: Minnesota Health Care Programs Community Based Services Manual: Home Care Nursing (HCN)

Intensive Residential Treatment Services (IRTS): Treatment exceeding 90 days requires authorization; readmission within 15 days counts toward 90-day total>90 days

CPT/HCPCS: H0019; Medical necessity: InterQual Adult and Geriatric Psychiatry - Residential Treatment Center

Long-Term Acute Care (LTAC): Notification required within 24 hours of admission; concurrent review required for additional days; discharge summary required upon discharge

Medical necessity criteria: InterQual LOC Long Term Acute Care appropriate subset chosen based on reason for admission

Nursing Facility Admission (for Custodial Care): Notification required within 24 hours of admission; update UCare upon Minnesota RUGS changes, transfers, or discharge to home; concurrent review required for additional days; discharge summary required upon discharge

UCare requires alphabetical RUG rates for authorization; medical necessity criteria: Not Applicable

Personal Care Assistant (PCA) and Community First Services and Supports (CFSS): Prior authorization required prior to service; an in-person assessment by UCare care coordinator, waiver case manager or contracted agency required before approval

CPT codes: reference DHS procedure codes Community First Services and Supports; Medical necessity: Minnesota Health Care Programs Provider Manual: PCA Services

Proton Beam Therapy: Prior authorization required prior to service

CPT codes: 77520,77522,77523,77525; Medical necessity: InterQual CP Procedures Proton Beam Radiotherapy (PBRT)

Psychiatric Residential Treatment Facilities (PRTF): Notification required within 24 hours of admission; concurrent review required for additional days; discharge summary required upon discharge

Medical necessity: Minnesota Health Care Programs Provider Manual: Psychiatric Residential Treatment Facilities

Spinal Cord Stimulation (SCS): Prior authorization required prior to trial and prior to permanent placement

CPT codes: 63650,63655,63663,63664,63685; Medical necessity: InterQual CP Procedures SCS Insertion

Substance Use Disorder Outpatient Treatment: Treatment exceeding six hours per day or 30 hours per week requires prior authorization; hours calculated in a rolling seven-day time span; authorizations can be given for up to a 28-day time span>6 hours/day or >30 hours/week (rolling 7-day)

CPT/HCPCS: H2035; Medical necessity: InterQual ASAM

Substance Use Disorder Residential Treatment: Notification within five days of admission; concurrent review required for additional days; discharge summary required upon discharge

CPT/HCPCS: H2036; Medical necessity: InterQual ASAM

Transcranial Magnetic Stimulation (TMS): Prior authorization required prior to service

CPT codes: 90867,90868,90869; Medical necessity: InterQual BH TMS

Vein Procedures: Prior authorization required prior to service

CPT codes: 36465,36466,36470,36471,36473,36474,36475,36476,36478,36479,36482,36483,37765,37766; Medical necessity: InterQual CP Procedures Ablation/Endovenous/Phlebectomy/Sclerotherapy

Wheelchair Accessories (Purchase and Rental): Prior authorization required before delivering or dispensing accessories or items that require authorization, including new, replacement or repaired accessories; repair/replacement of rental equipment is provider's responsibility; UCare reserves right to determine rental vs purchase

HCPCS examples: E0986,E1002...E2617; Medical necessity: InterQual CP Durable Medical Equipment; Minnesota Provider Manual: Equipment and Supplies

Wheelchair - Rental: Prior authorization required prior to delivery or dispensing power operated vehicles and power wheelchairs for items that require authorization; all months must be authorized; UCare reserves right to determine rental vs purchaseAll months must be authorized

HCPCS/K-codes examples: K0800...K0898; Medical necessity: InterQual CP Durable Medical Equipment; Minnesota Provider Manual: Equipment and Supplies

Wheelchair - Purchase: Prior authorization required prior to purchase for K0005-K0007, E1161, all power-operated vehicles and power wheelchairs; UCare reserves right to determine rental vs purchase

Codes: K0005-K0007, E1161 and all power-operated vehicles/power wheelchairs; Medical necessity: InterQual CP Durable Medical Equipment; Minnesota Provider Manual: Equipment and Supplies

OpenPayer

prior_authorization_and_notification_requirements

Coverage Summary (Part 1)

Authorization & Medical Necessity Criteria

Code Lists and Status

What Providers Must Do

Background and Definitions

Revision History