CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Arizona Complete Health Medicaid

Lists services and codes that require prior authorization for participating providers in the UnitedHealthcare Community Plan of Arizona Complete Care (ACC) Medicaid program and explains how to request authorization. Applies to providers serving ACC Medicaid members in Arizona.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Complete Health Medicaid

Policy CodePolicy N/A

Change TypeMinor / informational (no material changes)

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the listed phone numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-05-01policy effective date

Online & phonePA request methods

AHCCCS requiredcoverage prerequisite

Members <21pediatric rules

Extensive listscode-driven PA

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Coverage criteria and age-specific rules

Coverage criteria and exceptions

Covered when ALL of the following are met:

Services must be AHCCCS-covered benefits to be eligible for prior authorization.

Only medically necessary, cost-effective, federally- and state-reimbursable services are covered as outlined by AHCCCS.

Only one health care professional may request services on a prior authorization request form.

All rendering health care professionals, facilities and vendors must be actively registered with AHCCCS.

Exceptions (no prior authorization required)

Services delivered inside multi-specialty interdisciplinary clinics (MSIC) to CRS-designated or formerly designated members do not require prior authorization.

Cosmetic and reconstructive procedure coverage rules

Coverage depends on whether the procedure restores function or is cosmetic:

One of

Services or items furnished solely for cosmetic purposes are excluded from AHCCCS coverage.
Reconstructive procedures that treat a medical condition or improve/restore physiologic function may be covered with prior authorization and supporting clinical documentation.

For dental-related reconstructive services, providers should contact UnitedHealthcare Dental at 855-812-9208 for prior authorization instructions.

Durable Medical Equipment and diabetic supplies

Durable medical equipment (DME) and diabetic supplies coverage and vendor rules:

Prior authorization is required for DME items with a retail purchase or cumulative rental cost greater than $500.

To request DME items and incontinence supplies, providers should call Preferred Homecare at 800-636-2123; for items not provided by Preferred Homecare consult UHCprovider.com/AZcommunityplan for contracted vendors.

Items requiring special handling or noted limitations

Certain items (e.g., bone stimulators: E0466, E0483, E0486, E0620, E0636, E0638, E0641, E0642) and enclosed beds (E0693–E0710) are listed and require prior authorization or special processing.
Insulin pumps (e.g., E0745, E0766, E0784, E0984) and some diabetic supplies are noted as requiring special handling or prior authorization.

Chemotherapy prior authorization criteria

Chemotherapy injectable drugs require prior authorization:

Injectable chemotherapy drugs billed within J9000–J9999 (and specified listed J-codes, Q-codes, and miscellaneous billed injectables) require prior authorization; requests should be submitted online via the Provider Portal/One Healthcare ID as instructed.

Coverage criteria and special rules

Special coverage rules and pediatric distinctions:

Experimental and investigational services (and linked services) require prior authorization and are not covered without approval.

For members younger than 21, EPSDT rules apply (for example: coverage for enteral/TPN/oral supplements per AMPM Chapter 400, routine eye and hearing benefits as described); services for members <21 are reviewed under pediatric provisions.

For members 21 and older, certain items (e.g., hearing aids) require prior authorization and adult coverage follows AMPM Chapter 300 guidance.

Enteral, parenteral and oral in‑home nutritional therapy requires contacting Preferred Homecare and submission of clinical documentation and Certificate of Medical Necessity as specified by AHCCCS guidance.

Coverage criteria for members under 21

Prior authorization requirements for selected services for members younger than 21:

Hearing services: Specific hearing evaluation and hearing aid HCPCS/CPT codes are listed; diagnostic hearing evaluations (92591–92595 and related codes) generally do not require prior authorization for members <21, while hearing aids for members 21+ require prior authorization.

Home health and related services: Home health care services (G0299, G0300, S9123, S9124) require prior authorization.

Incontinence supplies must be requested through Preferred Homecare as the vendor; providers should call Preferred Homecare for supply requests.

Infusion and injectable medications: In‑home infusion services and injectable medications require prior authorization unless covered by Optum Infusion; providers should call Optum Infusion (888‑705‑4470) to request services/medications.

Prior authorization criteria for members <21

Services and items that require prior authorization for members younger than 21 include (representative groups):

Inpatient and post‑acute services: Prior authorization and notification of admission date required for acute care hospitals, acute inpatient rehabilitation, long‑term acute care hospitals and skilled nursing facilities.

Joint and major orthopedic replacements: Joint, total hip and knee replacement procedures require prior authorization for the codes listed in the document.

Laboratory services require prior authorization; for specified CPT/HCPCS codes providers are directed to contact LabCorp at 800‑788‑9743.

Non‑emergent air ambulance transport codes (A0430, A0431, A0435, A0436) require prior authorization.

Orthotics and prosthetics HCPCS L‑series codes listed require prior authorization; items with cost greater than $500 require prior authorization.

Members younger than 21 — authorization and coverage notes

Authorization and coverage notes specific to members younger than 21:

Prior authorization is required for all out‑of‑network services for members younger than 21.

Out‑of‑state services are approved only when emergent or when the service is unavailable in Arizona.

Outpatient occupational and physical therapy services for members <21 are reviewed for medical necessity; specific CPT codes are listed and PA timing rules apply.

Numerous HCPCS L‑series codes are associated with orthotics and prosthetics for members <21; prior authorization instructions and mappings are provided for those codes.

Covered with prior authorization and medical necessity review

Services covered with prior authorization and medical necessity review for members under 21:

Occupational, physical and speech therapy require prior authorization after the initial evaluation and before the initial therapy visit; ongoing therapy visits also require prior authorization and services are reviewed for medical necessity; no annual benefit limits apply for QMB members though requests are reviewed for medical necessity.

Pain injections and pain management procedures (e.g., CPT 64490, 64493) require prior authorization.

Physician‑administered drugs require prior authorization; pharmacy requests for physician‑administered medications must include J‑codes and NDCs as part of the request.

Certain advanced outpatient imaging (CT, MRI, MRA, PET, nuclear medicine/nuclear cardiology) require prior authorization/notification; ordering providers must notify prior to scheduling.

Site‑of‑service: prior authorization is required when requesting a service in an outpatient hospital setting; it is generally not required if the procedure is performed at a participating ambulatory surgery center (ASC) when applicable.

Prior authorization criteria for members <21

Additional prior authorization requirements for members younger than 21 by category:

Spinal surgery: prior authorization is required for the spinal surgery codes listed (examples include ranges 22100–22595 and 63001–63308).

Sterilization procedures: prior authorization is required for listed sterilization CPT codes and an appropriate Consent to Sterilization form is required per AHCCCS AMPM Chapter 400 Section 420 E.

Sleep apnea procedures and related surgeries require prior authorization for the listed codes (e.g., 21685, 41599, 42145).

Specialty/enclosed beds (DME) require prior authorization for the listed HCPCS bed codes (E0250–E0315 as applicable).

Site‑of‑service notes: multiple procedures include SOS guidance indicating whether outpatient hospital vs outpatient/ASC settings affect prior authorization requirements.

Prior authorization criteria for members <21

Prior authorization required for the following services; additional documentation or consent may be required:

Sterilization procedures (examples: 52601, 52630, 52647, 52648, 52649, 55250, 55801, 55821, 55831) require prior authorization and an appropriate Consent to Sterilization form as referenced by AMPM.

Transplant and CAR T‑cell therapy services (e.g., CAR T codes 0537T–0540T and associated J/Q/C codes) require prior authorization and supporting clinical documentation to justify medical necessity.

Device implantation and stimulators (examples listed in the document, e.g., E0747 and several CPT device implantation codes) require prior authorization.

Non‑emergent transportation (taxi and stretcher van) requires prior authorization and scheduling via Medical Transportation Management (MTM) as specified.

Code lists and coding notes

How to request prior authorization and required provider steps

Prior Authorization

How to request prior authorization

To request prior authorization, submit online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — Sign In with One Healthcare ID) or call the phone numbers listed on the Provider Portal and the member ID card (general phone: 800-445-1638; specialty lines shown in items below).

Online: UHCprovider.com > Sign In > Prior Authorization and Notification tool
Phone: 800-445-1638 (general) — specialty vendor/contact numbers appear in specific callouts below

Documentation Required

Coverage eligibility for prior authorization

To be eligible for prior authorization the requested service must be an AHCCCS-covered benefit and medically necessary. Non-network and out-of-state services require prior authorization with supporting documentation. All rendering providers, facilities and vendors must be actively registered with AHCCCS. Experimental/investigational services are not covered. Only one provider may submit a prior authorization request on a request form.

Key terms and vendor contacts

Covered benefits as defined by the Arizona Health Care Cost Containment System (AHCCCS)

DefinitionCovered benefits are those outlined and defined by the Arizona Health Care Cost Containment System (AHCCCS) and only AHCCCS-covered benefits are eligible for prior authorization

ExclusionsExperimental and investigational services are not covered benefits under AHCCCS

Provider registrationAll rendering health care professionals, facilities and vendors must be actively registered with AHCCCS

Regional Behavioral Health Authority (RBHA) — route for behavioral health services

RoutingBehavioral health services are provided through the Regional Behavioral Health Authority (RBHA) program

AssistanceFor RBHA assistance call 800-348-4058

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Complete Health Medicaid

Policy CodePolicy N/A

Change TypeMinor / informational (no material changes)

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the listed phone numbers.

SourceLink

On This Page

Potentially unproven services and pregnancy termination procedures require prior authorization; pregnancy termination PA must include clinical documentation and the Certificate of Medical Necessity per AHCCCS AMPM guidance.

Many surgical procedures across specialties (ENT, ophthalmology, digestive, gynecologic, musculoskeletal, etc.) list CPT codes that require prior authorization for members <21.

Services eligible for PA must be covered and reimbursable under AHCCCS
Non-network/out-of-state services: PA required with supporting documentation
All providers/facilities/vendors must be registered with AHCCCS
Experimental/investigational services: not covered — PA not applicable

Prior Authorization

Cardiology prior authorization note

Cardiology outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echocardiograms require prior authorization. For full details and the complete list of CPT codes that require authorization, providers should use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or visit UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization.

Cardiology PA required for outpatient diagnostic catheterizations, electrophysiology device implants, stress echoes
See UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization for CPT code list and submission guidance
Submit via Provider Portal or follow portal phone instructions

Note

Cardiovascular and related codes — prior authorization referenced

Cardiovascular-related diagnoses and ICD codes are referenced in the Cardiology prior authorization resources. Providers must reference those resources for the full set of ICD-10 and related codes that trigger prior authorization requirements.

Referenced cardiovascular diagnosis codes (examples included in policy): I70.333, I70.334, I70.335, I70.338, I70.339, I70.341, I70.342, I77.77, I77.79, I74.3–I74.9, I75.021–I75.029, I75.89, T82.818A, T82.868A, and device/implant codes (see online resources)
For CPT codes requiring PA for cardiology, see the Cardiology Prior Authorization resource on the Provider Portal

Prior Authorization

Hearing and hearing-aid codes and PA notes

Hearing services and hearing aids have age-dependent PA rules. For members younger than 21, many diagnostic hearing services (92590–92595, V50xx) do not require prior authorization; verify specific codes. For members 21 and older, hearing aids (V50xx, V51xx–V52xx series and related V5xxx codes listed in the policy) require prior authorization. Clinical documentation must accompany requests for hearing devices and supplies.

Members <21: diagnostic hearing codes 92590–92595 and V5010/V5011 — verify; many diagnostic services do not require PA
Members ≥21: hearing aids and many V5xxx codes require prior authorization (see policy code list)
Clinical documentation required to support medical necessity for hearing devices and supplies

Prior Authorization

Unclassified/temporary codes prior authorization

Unclassified and temporary HCPCS/CPT codes (for example C9399, J3490, J3590 and specified C9/C91/C91xx/C91xxx temporary codes) require prior authorization only when used for specific products listed in the policy. Certain new-to-market or miscellaneous-billed drugs and biologics require pre-determination; check the Review at Launch medication list and submit a pre-determination when recommended.

Temporary/unclassified codes: C9399, J3490, J3590 — PA required only for specific named products (see policy list such as Adzynma, Cosentyx IV, Nulibry, Omvoh, Revcovi, Vabysmo, Vyjuvek, Casgevy, Lantidra, Lyfgenia, etc.)
Review at Launch for New to Market Medications policy at UHCprovider.com/policies for up-to-date requirements and consider pre-determination

Prior Authorization

Inpatient / post-acute prior authorization

Inpatient admissions and post-acute facility services require notification and, for many facility types, prior authorization. Prior authorization and notification of the admission date are required for acute care hospitals, acute inpatient rehabilitation, long-term acute care hospitals, and skilled nursing facilities. Follow the Provider Portal submission process or the notification number on the member's ID card.

Notification required for inpatient admissions
Prior authorization and notification required for: acute care hospitals, acute inpatient rehabilitation, long-term acute care hospitals, skilled nursing facilities
Submit via Provider Portal or call the number on the member's health plan ID card

Prior Authorization

Non-emergent air ambulance

Non-emergent air ambulance transport (ground/air non-emergent transfers billed with A04xx codes) requires prior authorization. Providers must obtain PA before scheduling non-emergent air ambulance. Use the Provider Portal or the contact information in the policy to request authorization.

Non-emergent air ambulance HCPCS: A0430, A0431, A0435, A0436 (PA required)
Obtain PA prior to scheduling non-emergent air ambulance transport

Prior Authorization

Orthotics and prosthetics prior authorization

Orthotics and prosthetics items with a retail purchase or cumulative rental cost greater than $500 require prior authorization. Many L‑codes and related prosthetic HCPCS codes listed in the policy require PA — see the extensive L‑code listing for both members younger than 21 and those 21 and older. Requests for enteral/parenteral nutrition and related supplies are managed through Preferred Homecare (800-636-2123) and require clinical documentation and, where applicable, a Certificate of Medical Necessity.

DME/Prosthetics: PA required when retail purchase or cumulative rental exceeds $500
Numerous L‑codes (prosthetics/orthotics) listed in policy require PA — consult L‑code lists for age-specific rules
To request DME, enteral or parenteral supplies: Preferred Homecare 800-636-2123; accompany requests with clinical documentation and certificates of medical necessity as applicable

Billing Rule

Site-of-service prior authorization rules

Site-of-service rules: prior authorization is required only when services are requested in an outpatient hospital setting for certain procedures. If the same service is performed at a participating ambulatory surgery center (ASC), prior authorization may not be required. Providers are responsible for verifying site-of-service PA requirements for specific CPT codes (examples in policy include cardiovascular, imaging and specified surgical procedures).

PA applies when requesting services in an outpatient hospital setting for listed procedures
If performed at a participating ASC, PA may not be required — verify per code and site
Providers ordering advanced outpatient imaging must provide notification prior to scheduling (see Radiology Prior Authorization resources)

Prior Authorization

Skilled nursing and sleep apnea prior authorization

Skilled nursing facility placements require prior authorization. Sleep apnea procedures and surgeries (listed CPT/HCPCS codes) require prior authorization before scheduling. For sleep apnea durable medical equipment (e.g., CPAP/BiPAP) and related procedures, follow the PA process and include supporting clinical documentation.

Skilled nursing: PA required prior to placement
Sleep apnea procedures/surgeries (examples: CPT 21685, 41599, 42145 and related codes/E0315) require PA
Include clinical documentation supporting medical necessity for sleep apnea services and DME

Prior Authorization

Transportation prior authorization and scheduling

Transportation: Prior authorization is required for non-emergent taxi and stretcher van transportation and other non-emergent transport services listed in the policy. To schedule transportation, call Medical Transportation Management (MTM) at 888-700-6822. Verify member coverage and obtain PA before arranging non-emergent transport.

Non-emergent taxi and stretcher van require PA
To schedule transportation and obtain authorization: MTM 888-700-6822
Verify PA requirements for specific transportation codes before scheduling

External resourceBehavioral Health prior authorization code lists are available at providerexpress.com

UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization

Resource locationVisit UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior Authorization for CPT/HCPCS codes and instructions

PurposeProvides CPT lists and details for cardiology-related services that require prior authorization

Related codesCardiovascular ICD-10 diagnosis references are shown alongside cardiology PA details on the provider site

One Healthcare ID / online prior authorization access

Access methodSign in at UHCprovider.com using One Healthcare ID to access the Prior Authorization and Notification tool (or call 888-397-8129 for portal access support)

SubmissionPrior authorization requests can be submitted online via the UnitedHealthcare Provider Portal using One Healthcare ID

Phone supportPortal sign-in or access assistance available at 888-397-8129

Preferred DME vendor and contact for DME requests

Preferred vendorPreferred Homecare is the vendor for DME and enteral/parenteral/oral in-home nutritional services and incontinence supplies; call Preferred Homecare at 800-636-2123 to request DME or enteral supplies

Incontinence suppliesTo request incontinence supplies, contact Preferred Homecare as directed in the Provider Manual

Alternate vendorsFor DME not covered by Preferred Homecare, consult UnitedHealthcare Community Plan Provider Manual at UHCprovider.com/AZcommunityplan for contracted vendors

Certificate of Medical Necessity

Form requirementA Certificate of Medical Necessity must accompany requests for commercial oral nutritional supplements where applicable

Where to find formCertificate of Medical Necessity for Commercial Oral Nutritional Supplements available at azahcccs.gov > Resources > Guides-Manuals-Policies > AHCCCS Medical Policy Manual (AMPM) Chapter 400, Section 430-2

Supporting documentationClinical documentation must accompany requests to establish medical necessity for enteral/TPN/oral supplement services

Pediatric (EPSDT) vs Adult prior authorization guidance

EPSDT vs AdultEPSDT/pediatric rules (members <21) are governed by AHCCCS AMPM Chapter 400 (Section 430); adult prior authorization rules reference AMPM Chapter 300

Pediatric coverage examplesFor members younger than 21, enteral/TPN/oral supplements, routine eye and hearing services and other EPSDT benefits follow Chapter 400 guidance

Adult distinctionsFor members 21 and older, some services (e.g., hearing aids) require prior authorization and adult coverage follows AMPM Chapter 300 guidance

Optum Infusion

Vendor nameOptum Infusion is the contact/vendor for requesting in-home infusion services and injectable medications not otherwise covered

PhoneTo request injectable medications and in-home infusion services call Optum Infusion at 888-705-4470

PA notePrior authorization is required for injectable medications not covered by Optum Infusion

Preferred Homecare

Vendor namePreferred Homecare is identified as the vendor for enteral supplies and incontinence supplies and for DME requests

PhonePreferred Homecare contact: 800-636-2123

Service typesUsed for enteral/parenteral/oral in-home nutritional services, incontinence supplies, and certain DME items

Review at Launch

Policy referenceReview at Launch for New to Market Medications policy covers newly FDA-approved drugs and is available at UHCprovider.com/policies > For Community Plans > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan

RecommendationPre-determination is highly recommended for drugs on the Review at Launch Medication List

PA submissionPrior authorization requests for drugs should be submitted online via the UnitedHealthcare Provider Portal

Out-of-network services (members <21)

Out-of-network PAPrior authorization is required for all out-of-network services for members younger than 21

Provider registrationOut-of-network or out-of-state providers must provide documentation supporting the out-of-network request; all renderers must be actively registered with AHCCCS

Out-of-state approvalOut-of-state services are approved only when the service is emergent or unavailable in Arizona

Out-of-state services (members <21)

Approval conditionOut-of-state services for members younger than 21 are approved only when the service is emergent or unavailable in Arizona

PA requirementPrior authorization is required for out-of-state service requests (documentation required)

ReferenceSee Provider Manual and AMPM guidance for details on out-of-state authorizations

Site of service (SOS) - outpatient hospital

DefinitionSite of Service (SOS) – outpatient hospital: prior authorization is required when requesting service in an outpatient hospital setting

ASC exceptionPrior authorization is not required if the procedure is performed at a participating ambulatory surgery center (ASC) for many procedures

ExamplesSOS notes apply to numerous procedures (e.g., auditory, cardiovascular, urologic) listed in the document

Physician-administered drugs documentation

Documentation requirementService requests for physician-administered drugs must include the 'J' code and the medication NDC code

Pharmacy PA contactFor pharmacy prior authorization, contact UnitedHealthcare Pharmacy Prior Authorization Service as instructed in the Provider Manual

ExamplesMultiple J-codes (e.g., J1786, J2326, J2357, J2840, J3060, J3385, J3398) are referenced for PA and require J-code/NDC documentation

Site of service (SOS)

SOS notationSite of service (SOS) notes indicate when outpatient vs outpatient hospital settings apply and when PA is required

ApplicabilitySOS guidance is applied across many procedure groups (e.g., integumentary, urologic, cardiovascular) in the document

ASC exceptionMany listed procedures do not require PA if performed at a participating ASC

Sterilization consent

RequirementAn appropriate Consent for Sterilization form is required in addition to prior authorization for sterilization procedures for members younger than 21

AMPM referenceGuidance references AMPM Chapter 400, Section 420, Section E Sterilization at azahcccs.gov

Related codesSterilization CPT codes requiring PA include 52601, 52630, 52647, 52648, 52649, 55250, 55801, 55821, 55831

Consent to Sterilization

Form nameConsent to Sterilization form must accompany prior authorization requests for sterilization procedures for members younger than 21

Where to find guidanceSee AMPM Chapter 400, Section 420, Section E Sterilization at azahcccs.gov for details

PA requirementPrior authorization is required for listed sterilization procedure codes

MTM

VendorMedical Transportation Management (MTM) is the scheduling vendor for non-emergent transportation

How to scheduleTo schedule non-emergent transportation (taxi or stretcher van), call MTM at 888-700-6822

PA requirementNon-emergent transportation requires prior authorization as noted in the document