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Prior authorization requirements for Arizona Developmental Disabilities

Lists prior authorization requirements for participating health care professionals providing inpatient and outpatient services to UnitedHealthcare Community Plan of Arizona Developmental Disabilities members and explains how to request prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 800-445-1638.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

online & phonemethods to submit prior authorization requests

8/1/2025policy effective date

EPSDT <21EPSDT applies <21

Non-covered ≥21Allergy immunotherapy ≥21

~100+CPT/HCPCS/DME codes referenced

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria and general rules

General coverage principles

Covered when services are medical necessary and meet AHCCCS-defined coverage; exclusions and administrative rules apply.

Services must be covered benefits as defined by the Arizona Health Care Cost Containment System (AHCCCS).

Only medically necessary, cost-effective, federal- and state-reimbursable services are covered.

Services provided by non-network or out-of-state health care professionals require prior authorization and supporting documentation.

Experimental and investigational services are not covered benefits and require prior authorization or are excluded from authorization.

All rendering health care professionals, facilities and vendors must be actively registered with AHCCCS; only one health care professional may submit a prior authorization request form.

Allergy immunotherapy (age-based): For members younger than 21: allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary. For members 21 and older: allergy immunotherapy (including subcutaneous injections, SLIT or other routes) is not a covered benefit; allergy testing requires prior authorization if it meets severe reaction criteria (for example anaphylaxis to an unknown allergen).

Chemotherapy and supportive care

Outpatient injectable chemotherapy and specified cancer supportive care agents require prior authorization.

Prior authorization is required for outpatient injectable chemotherapy drugs administered for a cancer diagnosis (including intravenous, intravesical and intrathecal routes).

Chemotherapy injectable drugs billed under J9000–J9999, leucovorin (J0640), levoleucovorin (J0641/J0642), Lupron Depot (J1950), Q‑code chemotherapy products, and miscellaneous HCPCS for unassigned agents require prior authorization.

Cancer supportive care agents requiring prior authorization

Colony-stimulating factor drugs (examples: Filgrastim J1442; Pegfilgrastim J2506 and listed biosimilars/Q‑codes).
Bone-modifying agents (example: Denosumab J0897).

Surgery, cosmetic, reconstructive, and devices

Surgical procedures, cosmetic/reconstructive services and implantable devices have specific prior authorization rules; purely cosmetic procedures are excluded.

Procedures furnished solely for cosmetic purposes are excluded from coverage; prior authorization is required for cosmetic or reconstructive procedures when indicated.

Prior authorization is required for many surgical procedures listed in the prior authorization resources; providers should consult UHCprovider.com/AZcommunityplan for full code lists and submission instructions.

Implantable devices and stimulators

Prior authorization is required for implantation of stimulators and certain implantable devices (see listed CPT/HCPCS codes, e.g., bone growth stimulators E0747/E0748; neurostimulators).
For cochlear implants and related devices prior authorization is required (see device codes and age-specific rules).

Vision services (members <21 vs >=21)

Vision services coverage differs by member age.

Members younger than 21: Covered benefits include one routine eye exam every 12 months; regular single‑vision, bifocal or trifocal polycarbonate lenses; frame allowance up to $79.99 retail; one replacement pair of glasses if lost/stolen/damaged; members may pay difference for more expensive frames (waiver).

Members 21 and older: Prior authorization is required when services are medically necessary to diagnose or treat diseases and conditions of the eye. Routine vision benefits under EPSDT do not apply.

DME and enteral/parenteral nutrition coverage and prior authorization

Durable medical equipment (DME) and enteral/parenteral nutrition have code- and vendor-specific authorization requirements.

DME prior authorization is required for the HCPCS codes listed and for items that meet retail purchase or cumulative rental thresholds; some DME items require prior authorization regardless of dollar amount (examples and threshold referenced).

To request DME items or enteral/parenteral in‑home nutritional therapy, contact Preferred Homecare at 800-636-2123; clinical documentation including Certificate of Medical Necessity (where applicable) must accompany requests.

For members 21 and older, review AHCCCS AMPM Chapter 300, Policy 310‑GG for enteral/parenteral nutrition and related certificate/forms at azahcccs.gov.

Examples of DME requiring prior authorization

Bone stimulators, insulin pumps (E0656, E0745), wound vacs (E1009/E2402) and other HCPCS listed codes require prior authorization per the DME sections.

Surgical, genetic testing, and experimental service prior authorization

Select surgical procedures, genetic testing and experimental/investigational services require prior authorization.

Experimental or investigational services require prior authorization; refer to AMPM Chapter 300 Section 320‑B for policy details and consult the listed CPT/HCPCS example codes.

Select surgical procedures requiring prior authorization

Femoroacetabular impingement (FAI) procedure codes (examples: 29914, 29915, 29916) require prior authorization for members 21 and older.
Functional endoscopic sinus surgery (FESS) codes (examples: 31240, 31253–31259, 31267, 31276, 31287, 31288) require prior authorization for members 21 and older.

Genetic testing services not covered by LabCorp require prior authorization; providers should call LabCorp at 800-788-9743 to determine specific prior authorization requirements and routing. Representative codes are listed in the genetic testing section.

Prior authorization coverage criteria (summary)

Prior authorization requirements for members 21 and older — summary of commonly required services.

Eye care: prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye for members 21 and older. Providers should use the Provider Portal for submission.

Listed surgical/procedural codes

FAI and FESS procedure codes listed in the document require prior authorization for members 21 and older.
Orthognathic, orthotics/prosthetics and many other surgical CPT/HCPCS codes enumerated in the policy require prior authorization; consult online resources for full lists.

Genetic testing: prior authorization is required for services not covered by LabCorp; contact LabCorp at 800-788-9743 for routing and requirements.

Prior authorization and notification requirements (summary)

Prior authorization and notification are required for inpatient admissions, post‑acute services, joint replacement, and other specified services for members 21 and older.

Inpatient admissions and post‑acute services (acute care hospitals, acute inpatient rehabilitation, long‑term acute care hospitals) require notification and prior authorization of the admission date. Predetermination is highly recommended for listed drugs. Submit via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Joint replacement (total hip and knee and related codes) requires prior authorization; predetermination is highly recommended. Example codes are listed in the joint replacement section.

Nonemergent air ambulance transports require prior authorization for listed HCPCS codes (examples A0430, A0431, A0435, A0436).

Transport (nonemergent taxi and stretcher van) requires prior authorization and must be scheduled through Medical Transportation Management (888-700-6822).

Prior authorization and coverage notes

Notes on coverage and how to obtain prior authorization for specific code groups; predetermination encouraged.

For many listed CPT/HCPCS codes (orthognathic surgery, maxillofacial/jaw treatments, orthotics/prosthetics, etc.) prior authorization is required; consult UHCprovider.com/AZcommunityplan Prior Authorization and Notification resources for full code lists and fax forms.

Predetermination (prior authorization) is highly recommended for the drugs on the list and for services with significant cost or complexity. Providers should use the Provider Portal to submit requests.

Orthotics and prosthetics: orthotics/prosthetics codes require prior authorization; reasonable repairs or adjustments of purchased orthotics are covered. See orthotics L‑code listings for details.

Orthotics/prosthetics repair and replacement criteria

Rules for repair, replacement and documentation when authorizing orthotics and prosthetics for members 21 and older.

Reasonable repairs or adjustments of purchased orthotics are covered for all members to make the orthotic serviceable and/or when the repair cost is less than purchasing another unit.

A component of an orthotic or prosthetic will be replaced if, at the time authorization is requested, documentation is provided to establish the component is not operating effectively.

Authorization requests for orthotics/prosthetics should include documentation such as repair estimates, proof of prior unit and clinical justification as applicable.

Network and out-of-state coverage criteria

Network and geographic limitations that affect coverage and authorization.

Prior authorization is required for all out‑of‑network services.

Out‑of‑state services are a covered benefit only when the service is emergent or unavailable in Arizona; such services require appropriate authorization and documentation.

Outpatient therapy coverage and authorization

Outpatient therapy CPT/HCPCS codes are listed; prior authorization is required for specified codes for members 21 and older.

Specific outpatient therapy CPT/HCPCS codes (examples include 92507, 92508, 92521–92526, 97012, 97014, 97016, 97018, 97022, 97026, 97028, 97033–97039, 97110–97116, 97124, 97140, 97161–97168) are listed; prior authorization is required for the codes listed for members 21 and older.

Therapy services are covered in inpatient or outpatient settings as indicated; outpatient speech therapy is not a covered benefit.

Exception: Code 97799 (unlisted therapeutic procedure) is noted as prior authorization not required where specifically indicated.

Therapy coverage and limits

Therapy coverage includes visit limits and special provisions for qualified Medicare beneficiaries.

Outpatient speech therapy is not a covered benefit.

Occupational and physical therapy are covered in inpatient or outpatient settings; outpatient OT/PT are limited to 15 visits per benefit year (Oct 1–Sept 30) for restoration/maintenance and 15 visits per benefit year to acquire a new skill.

Qualified Medicare beneficiaries: certain services are covered for unlimited visits when medically necessary (refer to the qualified Medicare beneficiaries section).

Radiology prior authorization

Advanced outpatient imaging requires notification and prior authorization.

Health care professionals ordering advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) must provide notification prior to scheduling and submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool. Fax forms and portal resources are available at UHCprovider.com/AZcommunityplan.

Prior authorization requirement summary

Summary of prior authorization requirements by CPT/HCPCS code and site of service; providers should consult online resources for full lists.

This policy lists numerous CPT/HCPCS codes and site‑of‑service (SOS) designations that require prior authorization; many are designated outpatient or outpatient hospital. Providers must consult UHCprovider.com/AZcommunityplan Prior Authorization and Notification resources for full code lists and fax forms.

Site of service notes apply to many procedures; the SOS is commonly outpatient or outpatient hospital for the listed CPT codes.

Prior authorization required services (partial list)

Partial list of service categories and CPT/HCPCS codes that require prior authorization (representative excerpts).

Surgical categories requiring prior authorization (partial)

Spinal surgery codes (examples: 22100–22220, 22510–22633, 22800–22899, 63001–63170) require prior authorization.
Maxillofacial and oral procedures (examples: 52310, 52332, 52351–52356) require prior authorization where listed.
Sleep apnea procedures/surgeries and specialty/enclosed beds (examples: 21685; beds E0250/E0251/E0255) require prior authorization.

Transplant, CAR T‑Cell and high‑complexity services

Transplant and CAR T‑cell therapies require prior authorization and must be routed to the UnitedHealthcare Community and State Transplant Case Management Team (call 800‑418‑4994); clinical documentation to support medical necessity must accompany requests.

Prior authorization and operational instructions

Operational instructions and special routing for selected services that require prior authorization.

Code 38232 requires prior authorization only when billed for an oncology diagnosis (conditional PA).

Transportation: nonemergent taxi and stretcher van require prior authorization; to schedule call Medical Transportation Management at 888‑700‑6822.

Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the member ID card and fax the nurse‑provided form to Optum VAD Case Management at 855‑282‑8929.

Wound VACs and vein procedures require prior authorization; listed CPT/HCPCS codes and fax forms are available in the online resources. Providers should follow the specified routing and include clinical documentation to support medical necessity.

For many services and codes, specific fax forms and submission instructions are available at UHCprovider.com/AZcommunityplan Prior Authorization and Notification Resources; providers must include required documentation (e.g., J‑codes/NDCs for pharmacy requests).

Code lists and coding guidance

Outpatient therapy CPT codes requiring prior authorizationCPTCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing; group
92521	Evaluation of speech fluency (e.g., stuttering)
92522	Evaluation of speech sound production (e.g., articulation, phonology)
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance
92526	Treatment of swallowing dysfunction and/or oral function for feeding

Physical medicine / modality CPT codes requiring prior authorizationCPTCovered

97012	Application of a modality to 1 or more areas; traction, mechanical
97014	Application of a modality to 1 or more areas; hydrotherapy, each 15 minutes
97016	Application of a modality to 1 or more areas; vasopneumatic devices
97018	Application of a modality to 1 or more areas; paraffin bath
97022	Whirlpool
97026	Infrared
97028	Ultraviolet
97033	Iontophoresis
97034	Contrast bath
97035	Ultrasound

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Therapeutic procedure CPT codes requiring prior authorizationCPTCovered

97110	Therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112	Neuromuscular reeducation
97113	Aquatic therapy with therapeutic exercises
97116	Gait training (includes stair climbing)
97124	Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
97140	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage), one or more regions

Complex evaluation and therapeutic CPT codes requiring prior authorizationCPTCovered

97161	Physical therapy evaluation: low complexity
97162	Physical therapy evaluation: moderate complexity
97163	Physical therapy evaluation: high complexity
97164	Re-evaluation of physical therapy established plan of care
97165	Occupational therapy evaluation: low complexity
97166	Occupational therapy evaluation: moderate complexity
97167	Occupational therapy evaluation: high complexity
97168	Re-evaluation of occupational therapy established plan of care
97799	Unlisted physical medicine/rehabilitation service or procedure

How providers request authorization and required actions

Prior Authorization

How to request prior authorization

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com -> Sign In) or by phone at 800-445-1638.

Prior Authorization

When prior authorization is required

Prior authorization is required for services provided by non‑network or out‑of‑state providers and for allergy testing/treatments per the eligibility rules; documentation supporting out‑of‑network requests is required.

Prior Authorization

Chemotherapy and cancer supportive care prior authorization

Prior authorization is required for outpatient injectable chemotherapy drugs and certain cancer supportive care drugs (e.g., colony‑stimulating factors and bone‑modifying agents).

Definitions and vendor contacts

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

DefinitionEPSDT — Early and Periodic Screening, Diagnostic and Treatment: a federal requirement that covers necessary services for members younger than 21 when medically necessary; used to determine coverage for services such as allergy immunotherapy and vision for members <21.

ApplicabilityEPSDT coverage determinations apply only to members younger than 21; services covered under EPSDT may differ from adult coverage rules.

Relation to prior authorizationEPSDT-covered services for members <21 may be eligible for authorization when medically necessary; adult exclusions (≥21) do not apply to EPSDT benefits.

Arizona Health Care Cost Containment System (AHCCCS)

DefinitionAHCCCS — Arizona Health Care Cost Containment System: the state program that defines covered benefits and eligibility for prior authorization determinations.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Developmental Disabilities

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 800-445-1638.

SourceLink

On This Page

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Predetermination (prior authorization) is highly recommended for listed drugs and devices prior to service.

Hearing services and hearing aids for members 21 and older require prior authorization; for members younger than 21 prior authorization is not required. Contact information and codes are provided in the hearing section.

Incontinence supplies and infusion/in‑home services: these are benefits only when provided through designated vendors (Preferred Homecare/Optum Infusion). Prior authorization and vendor routing instructions are provided; infusion/injectable services not covered by Optum require prior authorization.

Certain high‑cost drugs and biologics (Q‑codes, J‑codes) and services require prior authorization; consult the drug lists and pharmacy prior authorization processes.

This is a partial list; providers should consult the full prior authorization lists on the Provider Portal for complete code coverage.

Examples include filgrastim J1442 and pegfilgrastim J2506 and chemotherapy injectable drugs billed J9000‑J9999.

Prior Authorization

Cochlear and implantable device prior authorization

Prior authorization is required for cochlear implants and related devices for members younger than 21 and for the listed device codes (for example CPT 69710; HCPCS L8614).

Providers should consult the portal resources for the full list of related CPT/HCPCS codes.

Prior Authorization

Surgical and behavioral health prior authorization

Prior authorization is required for bariatric surgery, behavioral health inpatient admissions, many cosmetic and reconstructive procedures, and the specified CPT/HCPCS surgical codes listed in the document.

Behavioral health inpatient admissions require prior authorization.
Bariatric surgery codes (e.g., 43644) require prior authorization; cosmetic procedures furnished solely for appearance are excluded.

Denial Risk

Non-covered services (experimental/investigational)

Experimental and investigational services are not covered benefits and therefore are excluded from authorization requests.

Documentation Required

Submission and provider registration rules

Only one health care professional may submit a prior authorization request form; all rendering professionals, facilities and vendors must be actively registered with AHCCCS to request authorization.

Prior Authorization

Enteral/parenteral nutritional therapy prior authorization

To request enteral, parenteral or in‑home nutritional therapy or supplies, call Preferred Homecare at 800‑636‑2123 and include the required clinical documentation and the Certificate of Medical Necessity for commercial oral nutritional supplements as applicable.

Certificate of Medical Necessity referenced in AMPM Chapter 300 Attachment C.

Documentation Required

Dental prior authorization contact

Dental prior authorization inquiries should be directed to UnitedHealthcare Dental at 855‑812‑9208; refer to the AHCCCS Medical Policy Manual Chapter 300, Section 310 for details.

Prior Authorization

DME prior authorization procedures

DME prior authorization is required for the HCPCS codes listed and for items that meet retail purchase or cumulative rental thresholds; Preferred Homecare is the contact for DME at 800‑636‑2123.

Some DME items require prior authorization regardless of dollar amount; items over specified cost thresholds are managed per the policy.

Prior Authorization

Experimental/investigational services prior authorization

Prior authorization is required for services considered experimental and/or investigational; specific example procedure and supply codes are listed in the policy and AMPM Chapter 300 Section 320‑B is the referenced guidance.

Example codes: 33477, A4638, G0293, S9991, 36514, A9274, G2000, S9992, 64722, E1831, S9988, S9994, 66180, G0276, S9990, S9996.

Prior Authorization

Select surgical procedures prior authorization (FAI, FESS)

For members 21 and older, prior authorization is required for listed femoroacetabular impingement (FAI) and functional endoscopic sinus surgery (FESS) procedure codes before scheduling.

FAI example codes: 29914, 29915, 29916; FESS example codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.

Prior Authorization

Eye care prior authorization

Prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye for members 21 and older.

Prior Authorization

Procedure codes requiring prior authorization

Prior authorization is required for the listed procedure codes for femoroacetabular impingement syndrome (FAI) and functional endoscopic sinus surgery (FESS) for members 21 and older; see the code lists in the policy.

FAI codes include 29914–29916; FESS codes include 31240, 31253–31259, 31267, 31276, 31287–31288.

Prior Authorization

Genetic testing prior authorization and LabCorp routing

Prior authorization is required for genetic testing services not covered by LabCorp; providers should call LabCorp at 800‑788‑9743 to determine prior authorization routing and requirements.

Representative genetic testing codes listed in the policy include 81265, 81302, 81321, 81323, 81325, 81401–81408, 81415–81416, and various cytogenetic codes (e.g., 88245–88291).

Prior Authorization

Hearing services prior authorization

Hearing evaluations and hearing aids for members 21 and older require prior authorization; for members younger than 21 prior authorization is not required. Hearing and eye care contacts are provided in the policy.

Hearing codes include 92590–92593, 92595 and V‑codes (V5010, V5011, V5014, V5030, V5040, V5100, V5050, V5120).
To obtain eye care services information call Nationwide Vision at 480‑961‑1702 (policy note).

Documentation Required

Incontinence supplies / Home infusion routing

Incontinence supplies are a benefit only when provided through Preferred Homecare; prior authorization and requests for supplies/services are routed to Preferred Homecare or Optum Infusion using the phone contacts in the policy.

Preferred Homecare phone: 800‑636‑2123; Optum Infusion for services/medications: 800‑985‑3059.

Prior Authorization

Infusion / injectable medication prior authorization routing

Prior authorization is required for infusion in‑home services and for injectable medications not covered by Optum Infusion; designated vendor contacts (Optum Infusion and Preferred Homecare) and phone numbers are provided.

Optum Infusion phone: 800‑985‑3059; Preferred Homecare phone: 800‑636‑2123.
Injectable medication examples and J‑codes are listed throughout the policy.

Prior Authorization

Injectable medication prior authorization (J-code list)

A long list of injectable medication HCPCS/J‑codes require prior authorization for members 21 and older; the policy lists numerous J‑codes as examples and instructs providers to include J‑codes/NDCs on requests.

Examples referenced include J3262, J0791, J7171, J1426, J1551, J1459, J1439, J0217, J1932, and many others in the J9000–J9999 range.

Prior Authorization

How to obtain prior authorization and notification (members 21+)

For members 21 and older, submit prior authorization and notification requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com -> Sign In); predetermination is highly recommended for drugs on the list.

Notification is required for inpatient admissions and certain facility types (acute care hospitals, acute inpatient rehabilitation, long‑term acute care hospitals).

Prior Authorization

Joint replacement prior authorization

Prior authorization is required for joint replacement procedures (total hip and knee) for the listed codes; predetermination is highly recommended.

Example joint replacement codes referenced include 24360–24363 and multiple hip/knee arthroplasty codes (see policy code lists).

Prior Authorization

Nonemergent air ambulance prior authorization

Prior authorization is required for nonemergent air ambulance transport for the listed HCPCS codes (A0430, A0431, A0435, A0436).

Submit prior authorization via the UnitedHealthcare Provider Portal per policy instructions.

Prior Authorization

Laboratory services prior authorization

Laboratory services may require prior authorization; providers should call the contact indicated in the policy to determine specific prior authorization requirements.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery codes listed in the policy require prior authorization for members 21 and older; predetermination is highly recommended and portal submission is the required channel.

Example orthognathic codes include 21121, 21123, 21125, 21127, 21141, and related codes listed in the policy.

Prior Authorization

Submission channel

The policy designates the UnitedHealthcare Provider Portal as the primary submission channel for prior authorization requests; access the portal at UHCprovider.com and click Sign In to use the Prior Authorization and Notification tool.

Prior Authorization

Predetermination recommendation and requirement

Predetermination (prior authorization) is highly recommended for the drugs on the list and is required for the CPT/HCPCS codes specified (examples include orthognathic surgery and orthotics/prosthetics codes).

Review at Launch policy for new‑to‑market medications is available at UHCprovider.com/policies > For Community Plans > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

Billing Rule

Coverage note for orthotics repairs/adjustments

Reasonable repairs or adjustments of purchased orthotics are covered to make the orthotic serviceable or when repair cost is less than purchasing another unit.

At authorization, documentation should support repair versus replacement decisions.

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com -> Sign In); predetermination is highly recommended for listed drugs and procedures.

Prior Authorization

Out-of-network prior authorization required

Prior authorization is required for all out‑of‑network services.

Prior Authorization

Out-of-state services limitation

Out‑of‑state services are a benefit only when the service is emergent or unavailable in Arizona; otherwise prior authorization/approval is not provided.

Documentation Required

Repair, replacement, and documentation expectations for orthotics/prosthetics

Components of orthotics/prosthetics will be replaced if, at the time authorization is requested, documentation establishes the component is not operating effectively; documentation must be provided with the authorization request.

Provide documentation of malfunction and clinical justification at time of authorization.

Prior Authorization

Prior authorization required (codes and procedures)

Prior authorization is required for the many CPT/HCPCS codes and services listed in the policy (examples include numerous therapy codes for members 21+ and other procedure groups); service requests must include required coding information.

Therapy and procedure code lists (e.g., 92507–92526, 97012–97039, 97110–97168) are in the policy; note that 97799 is explicitly noted as not requiring prior authorization.

Note

Exceptions (97799)

Exceptions: the policy explicitly notes that code 97799 does not require prior authorization.

Prior Authorization

Pharmacy prior authorization process and contacts

Pharmacy prior authorization requests must include J‑codes and NDCs for the medication requested; contact Pharmacy Prior Authorization by phone at 800‑310‑6826 or fax 866‑940‑7328 and use forms available at UHCprovider.com/AZcommunityplan.

Specialty pharmacy prior authorization fax: 866‑940‑7328.
Service request forms and medication‑specific forms available on the provider portal.

Prior Authorization

Radiology/Advanced imaging notification and prior authorization

Health care professionals ordering advanced outpatient imaging (certain CT/MRI/MRA/PET and nuclear procedures) must provide notification prior to scheduling and submit prior authorization requests via the UnitedHealthcare Provider Portal.

Use the Radiology Prior Authorization and Notification Program resources on UHCprovider.com/AZcommunityplan for details and fax forms.

Note

How to obtain prior authorization resources

For details and the CPT codes that require prior authorization, visit UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources (Radiology Prior Authorization and Notification Program) and use the available fax/forms.

Documentation Required

Site of service notes

Site‑of‑service (SOS) is specified for many procedure codes in the policy; commonly the SOS is outpatient or outpatient hospital — check the listed codes for the SOS designation.

Examples of SOS‑designated codes are provided in the policy (e.g., numerous ophthalmologic and arthroscopy codes).

Prior Authorization

Transplant/CAR T-Cell prior authorization and contact

For transplant and CAR T‑Cell therapy services and listed products, providers must call the UnitedHealthcare Community and State Transplant Case Management Team at 800‑418‑4994 and include clinical documentation to support medical necessity.

Clinical documentation must accompany authorization requests for transplant/CAR T‑Cell services.

Prior Authorization

Transportation prior authorization and scheduling

Transportation prior authorization is required for nonemergent taxi and stretcher van; to schedule, call Medical Transportation Management at 888‑700‑6822.

Prior Authorization

Sterilization prior authorization and consent

Sterilization procedures require prior authorization and the appropriate consent form as described in AMPM Chapter 400, Section 420; refer to the AHCCCS Medical Policy Manual for the Consent to Sterilization form.

Ensure the appropriate consent form is completed per AMPM Chapter 400, Section 420 when submitting authorization.

Prior Authorization

Durable medical equipment and sleep apnea procedures prior authorization

Specialty/enclosed beds and certain sleep apnea procedure codes require prior authorization as listed in the policy.

Example HCPCS for specialty/enclosed beds include E0250, E0251, E0255.

Prior Authorization

Surgical procedures prior authorization

Prior authorization is required for the listed spinal and other surgical CPT codes enumerated in the policy; obtain authorization prior to scheduling.

Spinal surgery codes listed (e.g., 22100–22220, 22510–22633, 22800–22899, 63001–63030 series) require prior authorization.

Prior Authorization

Prior authorization — assorted codes (including conditional oncology PA)

Prior authorization is required for the assorted CPT/HCPCS codes and services listed; note that code 38232 requires prior authorization only when billed for an oncology diagnosis.

Referenced codes include device, drug, and procedure codes (e.g., C9301, C9399, J3490, J9999, Q2041–Q2057, 38232, 33927–33983, E2402).

Prior Authorization

Transportation prior authorization

Transportation prior authorization is required for nonemergent taxi and stretcher van; to schedule transportation call Medical Transportation Management at 888‑700‑6822 (fax forms available).

Prior Authorization

Ventricular assist device notification and authorization

For ventricular assist device (VAD) authorization/notification, call the notification number on the back of the member's health plan ID card and fax the nurse‑provided form to the Optum VAD Case Management team at 855‑282‑8929.

VAD procedure and supply codes listed in the policy include 33927, 33928, 33929, 33975–33983 and Q0507–Q0509.

Prior Authorization

Wound VAC prior authorization

Wound VAC codes (for example E2402) require prior authorization; fax forms are available via the UnitedHealthcare provider resources.

Use the provider portal resources to obtain and submit the required fax forms.

Note

How to obtain prior authorization resources (portal primary)

Refer to the UnitedHealthcare Provider Portal Radiology Prior Authorization and Notification resources (UHCprovider.com/AZcommunityplan) for obtaining prior authorization forms and code lists; the portal is the recommended primary submission channel.

Services must be covered benefits as outlined and defined by AHCCCS to be eligible for prior authorization.

Reference guidanceProviders should refer to AHCCCS policies (AMPM) for specific coverage rules cited throughout this document.

Enteral/parenteral in-home nutritional therapy

DefinitionEnteral/parenteral in-home nutritional therapy includes enteral nutrition via gastrostomy tube, total parenteral nutrition (TPN), lipids and oral supplements provided in the home setting.

Prior authorization contactTo request enteral/parenteral in-home nutritional therapy or supplies, call Preferred Homecare at 800-636-2123.

Required documentationClinical documentation and the oral supplement Certificate of Medical Necessity (as applicable) must accompany service requests to establish medical necessity.

Experimental or investigational services

DefinitionExperimental or investigational services: services considered experimental and/or investigational are not covered benefits and require prior authorization when referenced; refer to AMPM Chapter 300, Section 320-B for details.

Operational notePrior authorization is required for services considered experimental/investigational; example CPT/HCPCS codes are listed in the document.

ReferenceSee AMPM Chapter 300, Section 320-B at azahcccs.gov for policy details and examples.

LabCorp phone routing

ContactLabCorp prior-authorization routing: providers should call LabCorp at 800-788-9743 to determine prior authorization requirements for genetic testing services not covered by LabCorp.

ContextPrior authorization is required for genetic testing services not covered by LabCorp; call LabCorp to determine requirements for specific tests and codes.

Referenced codesNumerous genetic testing CPT/HCPCS codes listed in the document reference LabCorp routing for PA determination.

Preferred Homecare / Optum Infusion

Preferred Homecare rolePreferred Homecare is the designated vendor to request DME and in-home infusion/incontinence supplies; contact for DME and enteral/parenteral requests.

Optum Infusion roleOptum Infusion handles in-home infusion services and injectable medication routing; providers call Optum Infusion for medication and infusion requests (800-985-3059).

Contact detailsPreferred Homecare: 800-636-2123; Optum Infusion: 800-985-3059 (for medications and infusion services).

Predetermination

DefinitionPredetermination: a recommended prior review process (predetermination/prior authorization) to determine coverage before services are rendered; highly recommended for listed drugs and procedures.

UsagePredetermination is highly recommended for drugs on the list and for certain procedures to establish coverage and avoid claim denials.

How to submitPredetermination requests should be submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Notification

DefinitionNotification: advance notice to UnitedHealthcare of an inpatient admission date; notification (and prior authorization) is required for acute care hospitals, acute inpatient rehabilitation and long-term acute care hospitals.

RequirementNotification of admission date is required for specified facility types and must be submitted via the Provider Portal Prior Authorization and Notification tool.

Related actionPredetermination is highly recommended for listed drugs; notification complements prior authorization for inpatient/post‑acute settings.

Provider Portal / Prior Authorization and Notification tool

Tool descriptionProvider Portal / Prior Authorization and Notification tool: UnitedHealthcare Provider Portal at UHCprovider.com; click Sign In in the top-right corner to access the Prior Authorization and Notification tool.

Primary submission channelProviders should submit prior authorization and predetermination requests online using the Prior Authorization and Notification tool on the portal.

Access notePortal resources include policies, forms and radiology prior authorization resources (UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources).

UHC Provider Portal submission

Submission methodUHC Provider Portal submission: submit prior authorization requests using the Prior Authorization and Notification tool on UHCprovider.com (Sign In at top-right).

Alternative contactsPhone submission options exist for some services (contact numbers provided in the document), but the portal is the preferred channel.

ResourcesPortal includes access to fax forms and program resources named in the policy (radiology program, pharmacy PA forms, etc.).

Orthotic repairs coverage

Coverage for repairs/adjustmentsReasonable repairs or adjustments of purchased orthotics are covered for all members to make the orthotic serviceable or when repair cost is less than purchasing another unit.

Component replacementA component will be replaced if documentation at the time of authorization establishes the component is not operating effectively.

Documentation expectedAuthorization requests should include documentation supporting the need for repair or replacement (repair estimate, proof of prior unit, clinical justification).

Outpatient speech therapy

DefinitionOutpatient speech therapy: explicitly noted that outpatient speech therapy is not a covered benefit under this plan.

ContrastThis contrasts with occupational and physical therapy, which are covered in inpatient and outpatient settings with limits.

Implication for providersDo not request prior authorization for outpatient speech therapy as it is not a covered benefit; refer to therapy coverage rules for OT/PT.

Therapy coverage scope

Scope of coverageTherapy coverage: Occupational and physical therapy are covered in inpatient or outpatient settings; outpatient speech therapy is not covered.

LimitsOutpatient OT/PT limited to 15 visits per benefit year for restoration/maintenance and 15 visits per benefit year to acquire a new skill (Oct. 1–Sept. 30).

Qualified Medicare beneficiariesCertain services for qualified Medicare beneficiaries may be covered for unlimited visits when medically necessary (see detailed policy).

Site of service (SOS)

DefinitionSite of service (SOS): indicates the setting where the procedure is performed (for example, outpatient or outpatient hospital) and is specified for many procedure codes in the document.

UsageSOS designations accompany CPT codes to clarify where services require prior authorization (commonly outpatient or outpatient hospital in listings).

Where to find detailsConsult the code listings and radiology prior authorization resources on UHCprovider.com/AZcommunityplan for SOS specifics and fax forms.

Radiology PA resources reference

Resource locationRadiology PA resources: visit UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources > Radiology Prior Authorization and Notification Program for details and fax forms.

PurposeThis resource provides the CPT codes that require prior authorization for advanced imaging and associated submission instructions.

Access noteFax forms and program guidance are available through the listed portal resources.

38232 oncology-only PA

Definition38232 oncology-only PA: CPT code 38232 requires prior authorization only when billed for an oncology diagnosis.

Operational noteWhen 38232 is billed for non-oncology diagnoses, prior authorization is not required per the policy note.

ReferencePolicy text includes the conditional note that 38232 requires PA only for an oncology diagnosis; fax forms available via portal resources.

Sterilization consent requirement

RequirementSterilization consent requirement: sterilization procedures require prior authorization and the appropriate consent form as described in AMPM Chapter 400, Section 420.

Where to obtain formRefer to AMPM Chapter 400, Section 420 at azahcccs.gov for the Consent to Sterilization form and related guidance.

Related codesMultiple sterilization CPT codes are listed in the policy and require prior authorization with the consent documentation.

Medical Transportation Management

ContactMedical Transportation Management: to schedule nonemergent taxi or stretcher van transportation, call 888-700-6822.

RequirementTransportation prior authorization is required for nonemergent taxi and stretcher van services.

How to scheduleProviders or members should call the listed Medical Transportation Management number to arrange authorized nonemergent transport.

Optum VAD Case Management

Contact for VADOptum VAD Case Management: providers must call the notification number on the back of the member's health plan ID card and fax the nurse-provided form to Optum VAD Case Management at 855-282-8929 for ventricular assist device prior authorization.

RequirementPrior authorization is required for ventricular assist device (VAD) codes; follow the notification and fax process described.

Operational stepCall the member's plan notification number, obtain the nurse-provided form, then fax to 855-282-8929 to complete the VAD authorization process.