CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Lists services, drugs, and procedures that require prior authorization for participating UnitedHealthcare Community Plan of Pennsylvania CHIP providers and explains submission methods and contact info for requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com, or by phone at 888-702-2202, or by fax at 866-968-7582.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-02-01Policy effective date

888-702-2202PA phone

866-968-7582PA fax

multipleDrug codes included

$500DME PA threshold

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.

Services and Codes Requiring Prior Authorization

Prior authorization criteria excerpts and summary

This section lists services, procedures, and codes that require prior authorization or notification for UnitedHealthcare Community Plan (effective 2026-02-01). It consolidates prior-authorization requirements, routing instructions, and examples of CPT/HCPCS codes. Providers should submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone/fax where noted.

General prior authorization routing: Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) after signing in with a One Healthcare ID. If needed, call 888-702-2202 or fax 866-968-7582 for general PA requests. Radiology PA requests: call 866-889-8054. Transplants and CAR T-cell therapies: call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246.

Prior authorization applies to a broad list of services (examples): Abortion (codes: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857); Bariatric surgery (43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43860); Behavioral health services — call the number on the back of the member's ID for specific PA codes.

Injectable medications and chemotherapy: Prior authorization is required for many injectable specialty and oncology drugs administered outpatient. Examples include therapeutic radiopharmaceuticals and chemotherapy injectables (HCPCS J9000-J9999; Leucovorin J0640; Lupron Depot J1950; Q-codes). See Injectable medications list (J and Q codes) for many specific agents — examples: filgrastim/pegfilgrastim family (J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125), Denosumab (J0897), many biologics and clotting factors (J7170, J7199, J7187, etc.). For unclassified codes (C9399, J3490, J3590) and miscellaneous HCPCS billed drugs, PA is required.

Cancer supportive care: Colony-stimulating factors and bone-modifying agents require PA, including when used for non-oncology diagnoses in some cases (see specific code list).

Genetic and molecular testing: Prior authorization/notification is required for a wide range of molecular and genetic CPT codes (examples across 81163, 81164, 81228–81229, 81277, 81400–81417, 81431–81479, 81518–81522, 87505–87507, many 00xxU/01xxU–04xxU codes, and numerous 02xxU–04xxU series). The ordering provider must include the performing laboratory and test name to complete authorization.

Durable medical equipment, orthotics and prosthetics: PA required only for codes with a retail purchase or cumulative rental cost > $500. Examples: DME A9279, A9280, A9900; HCPCS E0194, E0265–E0277, E0300; orthotics/prosthetics L0112, L0170, L0456, L0462, L0464, L0480–L0486, L0624, L0629, L0631–L0632, L8609–L8631, L8659.

Home health and hospice: Home health prior authorization required in outpatient settings for codes such as G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474. Hospice prior authorization required (example code T2045).

Inpatient notifications/authorizations: Notification required for inpatient admissions; prior authorization and notification of admission date required for post-acute inpatient services and certain facilities. Specific procedures (e.g., VAD) require contacting the notification number on the member's ID and faxing forms to specialty teams as instructed (Optum VAD team fax 855-282-8929).

Radiology: Prior authorization required for certain advanced outpatient imaging procedures (certain CT, MRI, MRA, PET scans, nuclear medicine/nuclear cardiology). Ordering providers must provide notification prior to scheduling. Call 866-889-8054 or use the Provider Portal for radiology PA. See Radiology Prior Authorization lists for CPT codes.

Procedures and surgeries: Prior authorization required for many surgical procedures including joint replacement and major orthopedics (example CPT ranges listed in Radiology/Procedures sections), hysterectomy (58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290–58292, 58542–58544, 58550, 58552–58573, 58570–58571), rhinoplasty/septoplasty (30400–30462 series), sinuplasty (31295–31298).

Transplants and CAR T-cell therapy: Prior authorization required — call 888-936-7246 or the notification number on the back of the member's ID card.

Site-of-service: Prior authorization for services in an outpatient hospital setting is required for select codes.

Operational notes: For many genetic/molecular tests, the authorization process requires the laboratory name and specific test identifier; some tests require pre-sequencing BRCA notification. For certain specialty services (VAD, transplant, CAR T), providers must call designated specialty teams and follow fax/form instructions.

Codes and Code Groups Mentioned

Genetic testing and breast reconstruction codes requiring prior authorizationmixedCovered

81162	BRCA1/BRCA2 single site or known familial variant testing
81212	BRCA1/BRCA2 full sequence testing (example code listed)
81216	BRCA testing (example code listed)
81432	BRCA panel or related genetic test (example code listed)
19316	Breast reconstruction code listed
19318	Breast reconstruction code listed
19325	Breast reconstruction code listed
L8600	Breast prosthesis (example HCPCS)

Sample colony-stimulating factor codesHCPCSCovered

J0185	Aprepitant (Cinvanti) injectable
J1449	Eflapegrastim (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym) biosimilar

Injectable colony-stimulating factor related diagnoses (ICD-10)ICD-10

No codes listed

Chemotherapy injectable HCPCS/J-codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs (range)
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional code)
J1950	Lupron Depot

Multiple ICD-10 oncology and skin diagnosis codesICD-10

C43.*	Melanoma and related skin cancer codes (examples listed)
C44.*	Other malignant neoplasms of skin (examples listed)
C4A.*	Malignant neoplasms of overlapping sites of skin
D03.*	Melanoma in situ codes (examples listed)
D04.*	Carcinoma in situ of the skin (examples listed)

Selected DME HCPCS codesHCPCSCovered

E0194	Durable medical equipment HCPCS code listed (requires PA if cost > $500)
E0328	Durable medical equipment HCPCS code listed
E0460	Durable medical equipment HCPCS code listed
E0693	Durable medical equipment HCPCS code listed

Selected CPT procedure codesCPTCovered

31599	Unlisted procedure code requiring prior authorization
31750	Procedure code listed
31899	Procedure code listed
45399	Unlisted procedure code listed

Genetic/molecular CPT pairs shownmixed

64856	Appears paired with many U-codes in the mapping text
64892	Appears paired with many U-codes in the mapping text
64896	Appears paired with many U-codes in the mapping text
69300	Appears paired with many U-codes in the mapping text

Selected injectable medication HCPCS/J-codesHCPCSCovered

J0881	Aranesp (listed as requiring prior authorization)
J1439	Injectafer (listed)
J7175	Coagadex (listed)
J7187	Humate-P (listed)
J7199	Hemophilia clotting factor, not otherwise classified (listed)

Selected injectable drug codesHCPCSCovered

J1552	Immune globulin (IVIG) product (example listed)
J1554	Immune globulin (IVIG) product (example listed)
J1557	IVIG/immune globulin related code
J1559	IVIG/immune globulin related code
J1566	IVIG/immune globulin related code
J1568	IVIG/immune globulin related code
J1569	IVIG/immune globulin related code
J1575	IVIG/immune globulin related code
J1599	IVIG/immune globulin related code
J1442	White blood cell colony stimulating factor

Additional injectable drug codes (examples)HCPCSCovered

J2323	Tysabri
J1303	Ultomiris
J2326	Spinraza
J1745	Remicade
J7182	Novoeight

Sample orthotics/prosthetics L-codesHCPCSCovered

L1700	HCPCS L-code (orthotic/prosthetic) listed as requiring prior authorization in this section
L1710	HCPCS L-code listed as requiring prior authorization
L1720	HCPCS L-code listed as requiring prior authorization

Radiology and miscellaneous service codesCPT | HCPCSCovered

T1024	Pediatric day services (PDHC) — prior authorization required
T1000	Private duty nursing — prior authorization required
77520	Proton beam therapy — prior authorization required

ENT procedures (sinuplasty)CPTCovered

31295	Sinuplasty — prior authorization required
31296	Sinuplasty — prior authorization required
31297	Sinuplasty — prior authorization required
31298	Sinuplasty — prior authorization required

Sinuplasty and related site-of-service codesCPTCovered

31295	Sinuplasty
31296	Sinuplasty
31297	Sinuplasty
31298	Sinuplasty
69205	Auditory system procedure (site-of-service note)

Spinal surgery codes noted as requiring prior authorizationCPTCovered

22100	Spinal surgery
22554	Spinal surgery
22830	Spinal surgery
63003	Spinal surgery

Spinal/cranial surgery codesCPTCovered

22100-22899, 22510-22633, 22800-22861, 63001-63173, 63185, 63200-63308, 0098T

Various spinal and cranial surgery CPT codes listed in this section (examples drawn from contiguous sequences).

Drug/Gene therapy/transplant codesHCPCSCovered

J3387, J3389, S2060, S2061, S2152, J3391, J3392, J3393, C9399, J3490, J3590

Drug, supply and unclassified HCPCS/J-codes related to transplant, gene therapy and other specialized services that require prior authorization or special handling.

DME prior authorization cost threshold

RuleRetail purchase or cumulative rental cost greater than $500 requires prior authorization for listed DME codes.

ScopeApplies to durable medical equipment (DME) HCPCS/CPT codes specifically listed in the policy (examples include A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300).

When measuredThreshold evaluated on retail purchase price or cumulative rental cost for the item(s).

How Providers Must Request Prior Authorization

Prior Authorization

How to submit prior authorization requests

Providers must submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. To get started, go to UHCprovider.com, sign in using your One Healthcare ID and password, then select the Prior Authorization and Notification tab. If you do not have a One Healthcare ID, visit UHCprovider.com/access. Requests may also be submitted by phone at 888-702-2202 or by fax to 866-968-7582 (fax form available at Prior Authorization Forms).

Online: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)
Phone: 888-702-2202
Fax: 866-968-7582

Prior Authorization

Behavioral health prior authorization routing

For behavioral health services and specific codes requiring behavioral health routing, providers should call the phone number on the back of the member's health plan ID card to obtain prior authorization instructions.

Definitions and Reference Notes

Prior authorization

DefinitionPrior authorization is the requirement that health care professionals notify and receive approval before scheduling specified services listed in this policy.

Submission methodsRequests may be submitted online using the Prior Authorization and Notification tool on UHCprovider.com, by phone, or by fax as provided in the policy.

Applies toInpatient and outpatient services and specific drugs, devices, procedures and tests enumerated in the policy.

Behavioral health network

DefinitionDesignated behavioral health network: many benefit plans provide coverage for behavioral health services through a designated behavioral health network.

RoutingFor specific behavioral health codes requiring prior authorization, providers should call the phone number on the back of the member's health plan ID card.

Document Revision History

2026-02-01effective_dateLatest

Policy effective date set for UnitedHealthcare Community Plan of Pennsylvania CHIP prior authorization requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com, or by phone at 888-702-2202, or by fax at 866-968-7582.

SourceLink

On This Page

How to obtain authorizationSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com, or by phone/fax as specified in the policy.

DME retail purchase/cumulative rental cost threshold

Dollar amount$500

UnitRetail purchase or cumulative rental cost

ApplicabilityThreshold applies to listed durable medical equipment (DME) and orthotic/prosthetic items as specified in the policy.

Orthotics/prosthetics prior auth threshold

TriggerPrior authorization required only for orthotics/prosthetics codes listed when retail purchase or cumulative rental cost exceeds $500.

ExamplesSample L-codes listed in the policy (e.g., L0112, L0170, L0456, L0462) require PA when cost threshold met.

MeasurementBased on retail purchase price or cumulative rental cost for the listed code(s).

Prior Authorization

Cancer supportive care - injectable and colony-stimulating factors

Certain cancer supportive care drugs, including injectable colony-stimulating factors and other named supportive agents, require prior authorization when administered in the outpatient setting for a cancer diagnosis. Some listed codes also require prior authorization when used for non-oncology diagnoses. See the injectable medications section for additional injectable drug prior authorization requirements.

Affected codes include (examples): J1442, J1447, Q5108, Q5110, Q5111, J1448, J2506, Q5101, Q5120, Q5122, Q5125
Pegfilgrastim and biosimilars (e.g., J2506, Q5122, Q5120, Q5111, Q5108) and other colony-stimulating factors (e.g., J1449, J1447, J2820) require authorization
Some codes require prior authorization only for oncology diagnoses — verify per code guidance

Prior Authorization

Antiemetics requiring prior authorization

Specific antiemetic HCPCS/J-codes require prior authorization. Verify the exact product code prior to administration and submit authorization requests through the Provider Portal or phone.

Listed antiemetic codes include: J1434, J2468, J1453, J1456, J1454, J1627

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors require prior authorization when used with a type 2 diabetes diagnosis. Confirm device code and submit prior authorization via the Provider Portal or the listed contact methods.

Affected HCPCS/Codes include: A4226, A9278, A4239, E0787, A9276, E2102, A9277, E2103

Prior Authorization

Enteral and in-home nutrition prior authorization

Enteral services and in-home nutritional therapy require prior authorization. Providers must submit prior authorization requests for enteral supplies and in-home nutrition using the Provider Portal or contact methods listed.

Enteral product and supply codes: B4035, B4036, B4100
In-home nutritional therapy codes: B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158

Prior Authorization

Procedure prior authorization

Selected procedures across multiple specialties require prior authorization. This includes certain ENT, sinus, orthopedic, spinal, joint replacement, cosmetic/reconstructive, and other major procedures. Prior authorization may be site-of-service dependent — when the procedure is requested in an outpatient hospital setting, verify whether authorization is required.

Examples of procedures requiring authorization: femoroacetabular impingement repair (29916), functional endoscopic sinus procedures (31240–31267, 31295–31298 when applicable), rhinoplasty/septoplasty (30400–30462), spinal surgery (e.g., 22100–22856, 63003–63005), joint and knee replacement procedures (see knee/hip joint codes)
Site-of-service note: prior authorization is required only when requesting certain services in an outpatient hospital setting — confirm per-procedure SOS guidance

Prior Authorization

Non-emergent air ambulance transport

Non-emergent air ambulance transport requires prior authorization. Providers must obtain authorization before arranging non-emergent air transport.

Affected HCPCS codes: A0430, A0431, A0435, A0436
Also includes codes S9960, S9961 as applicable

Prior Authorization

Other services requiring prior authorization

Several other services require prior authorization, including pediatric day health services, private duty nursing, potentially unproven services, prostate procedures, proton beam therapy, home health services (when applicable), hospice services, hysterectomy procedures, orthotics/prosthetics above cost thresholds, and many injectable medications. Use the Provider Portal or contact numbers to submit authorization requests and include required documentation.

Pediatric day services: T1024
Private duty nursing: T1000, T1002, T1003
Prostate procedures: 37243, 52441, 52442, 53850
Proton beam therapy codes: 77520, 77522, 77523, 77525
Home health and home care: G0156, G0162, G0299, G0300, G0493–G0496
Hospice: T2045
Hysterectomy CPTs include 58150, 58152, 58180, 58260, 58542–58573

Prior Authorization

Sinuplasty prior authorization and site-of-service note

Sinuplasty procedures require prior authorization. Additionally, site-of-service rules apply — prior authorization is required only when the procedure is performed in the outpatient hospital setting as noted.

Sinuplasty CPT codes: 31295, 31296, 31297, 31298
Site-of-service note: authorization required only when performed in an outpatient hospital setting

Prior Authorization

Selected surgical procedures requiring authorization

Selected surgical procedures require authorization and, for some high-complexity procedures, additional notification steps. This includes transplants, spinal surgery, maxillofacial/orthognathic surgery, stimulator implants, VADs, and many other major surgical categories. Always confirm code-specific requirements and follow special submission processes where indicated.

Spinal surgery and major procedures: numerous CPT codes (e.g., 22100–22856, 22548, 22551, 22554, 22630, 22633, 63003–63005, etc.)
Orthognathic/maxillofacial codes: 21121–21299 range as applicable
Stimulators and bone growth stimulators: E0747–E0760, L8686–L8688 (implantation codes)
Ventricular assist devices (VAD): call the notification number on the member's ID card and fax required documentation to the Optum VAD Case Management Team at 855-282-8929

Prior Authorization

Transplant and CAR T‑cell therapy prior authorization and notification

Transplant and CAR T‑cell therapy services require prior authorization and additional notification. For these services (including Abecma, Breyanzi, Kymriah, Tecartus, Yescarta and similar therapies), providers must call the UnitedHealthcare Community and State Transplant Case Management Team or use the notification number on the member's ID card before proceeding.

Contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246
Also call or follow the notification number on the back of the member's health plan ID card for required preauthorization and case management steps

Prior Authorization

Wound VAC prior authorization

Wound VAC (negative pressure wound therapy) devices require prior authorization. Submit requests via the Provider Portal or contact methods and include the device code and clinical justification.

Wound VAC HCPCS code: E2402

ApplicabilityApplies to mental health and substance use services identified in the policy.

Provider portal prior authorization tool

DefinitionProvider portal Prior Authorization and Notification tab: the online tool on UHCprovider.com used to submit prior authorization and notification requests; access requires One Healthcare ID.

How to accessSign in at UHCprovider.com (top-right Sign In) with One Healthcare ID, then select the Prior Authorization and Notification tab on the dashboard.

Alternate methodsPhone and fax submission options remain available (phone and fax numbers provided in policy).

DME PA threshold

DefinitionDME prior authorization threshold: prior authorization is required only when specified DME codes have a retail purchase or cumulative rental cost of more than $500.

ExamplesPolicy lists DME HCPCS codes subject to the threshold (e.g., A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300).

EvaluationThreshold is applied per listed code based on retail purchase or cumulative rental cost.

Genetic/molecular testing PA

ScopeGenetic and molecular testing CPT/HCPCS codes listed in the policy require prior authorization.

SettingsTesting often requires authorization when performed in outpatient or home care settings and when billed with the mapped CPT/HCPCS codes shown.

DocumentationAuthorization/notification requires indication of the ordering laboratory and test name; some entries note the laboratory must notify UnitedHealthcare.

UnitedHealthcare

EntityUnitedHealthcare: the payer referenced throughout this policy (UnitedHealthcare Community Plan of Pennsylvania CHIP).

RoleOperates the Provider Portal (UHCprovider.com) and manages prior authorization, notification, and specialized case management teams referenced in the policy.

ContactsPhone and fax contact methods for prior authorization are provided in the policy (e.g., numbers on member ID card or policy contact numbers).

Prior authorization/notification (genetic/molecular testing)

RequirementWhen requesting authorization for genetic/molecular testing codes listed, the ordering provider must indicate the laboratory and test name to complete the prior authorization or notification.

Laboratory notificationSome test entries note that the laboratory conducting the test will notify UnitedHealthcare as part of the process.

Code examplesPolicy lists many U-codes and mappings (examples include 0018U, 0239U, 0306U, 0320U) that require prior authorization/notification and lab identification.

Notification

DefinitionNotification: in the context of admissions, prior authorization and notification of the admission date is required for specified post-acute inpatient services (e.g., acute care hospitals).

ApplicabilityApplies to inpatient admission notifications and certain facility admissions listed in the policy.

How to provideFollow the policy's prior authorization and notification submission instructions (portal, phone, fax).

Prior authorization (orthotics/prosthetics threshold)

DefinitionOrthotics/prosthetics prior authorization threshold: prior authorization is required for listed orthotics and prosthetics codes only when retail purchase or cumulative rental cost exceeds $500.

ExamplesPolicy lists many L-codes subject to this threshold (e.g., L0112, L0170, L0456, L0462, L0480, L0631).

MeasurementThreshold assessed on retail purchase price or cumulative rental cost for the listed code(s).

Prior authorization general definition

DefinitionPrior authorization: requirement that health care professionals notify and receive approval before scheduling specified advanced outpatient imaging procedures or other listed services.

ExamplesIncludes certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures requiring notification and authorization prior to scheduling.

Provider responsibilityOrdering providers must notify prior to scheduling and may request authorization via the Provider Portal or by calling the phone number provided in the policy.

Prior Authorization and Notification tool

DefinitionPrior Authorization and Notification tool: the online Prior Authorization and Notification tab on the UnitedHealthcare Provider Portal (UHCprovider.com) used to submit prior authorization and notification requests.

AccessAccess requires signing in with a One Healthcare ID; after sign-in, select the Prior Authorization and Notification tab on the dashboard.

Alternate optionsRequests may also be submitted by phone or fax as noted in the policy if needed.

Site of service (SOS)

DefinitionSite of service (SOS): prior authorization requirements may depend on whether the service is performed in an outpatient hospital setting versus an ambulatory surgical center (ASC) or office; some services require PA only when performed in an outpatient hospital.

ExampleSinuplasty (CPT 31295–31298) requires prior authorization only when performed in an outpatient hospital setting as noted in the policy.

Provider actionVerify site-of-service rules in the policy when requesting authorization for specific codes.

VAD

AbbreviationVAD = Ventricular Assist Devices.

DefinitionMechanical pump that takes over the function of the heart; VADs require prior authorization per the policy.

SubmissionProviders must call the notification number on the member ID card and fax the required form to the Optum VAD Case Management Team at 855-282-8929 as instructed.

Stimulator / Neurostimulator

DefinitionStimulator / Neurostimulator: devices that send electrical impulses, including neurostimulators and bone growth stimulators; implantation requires prior authorization.

ExamplesPolicy lists bone growth stimulator HCPCS codes E0747, E0748, E0749 and neurostimulator-related codes (L868x series) requiring authorization.

Provider actionSubmit prior authorization per policy instructions for implantation of these devices.

Transplant / CAR T-cell therapy

DefinitionTransplant / CAR T-cell therapy: transplant services and CAR T-cell therapies require prior authorization and coordination with the UnitedHealthcare Community and State Transplant Case Management Team.

ContactProviders must call the Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card to initiate authorization/coordination.

ExamplesIncludes CAR T therapies such as Abecma, Breyanzi, Kymriah, Tecartus, Yescarta and related codes enumerated in the policy.