UnitedHealthcare CHIP Prior Auth Policy Update

Extracted coverage rules

Summary of authorization criteria from the excerpted sections

Prior authorization is required for many specific procedures, services and drug codes as listed in this document, except where noted (see exceptions below).

Prior authorization is not required for emergency or urgent care.

Out-of-network prior authorization requests must be made by an in‑network provider for all procedures and services except emergent or urgent care.

For oncology-related J‑codes and other injectable medications, prior authorization is required when billed with an Oncology diagnosis; the document lists specific J‑codes and effective dates and instructs oncology prior authorization submissions via the UnitedHealthcare Provider Portal or the oncology phone line.

Some medication groups and biologics are subject to a Review at Launch process; pre-determination is highly recommended for newly approved drugs.

Partial criteria and instructions

Example criteria entries from this section:

Circumcision: prior authorization required for members older than age 1 (Prior Authorization Effective Date = Jan. 1, 2015).

Cochlear implants (example CPT 69729) are listed as requiring prior authorization with an effective date noted (Cochlear implant effective date example March 1, 2023 in brief).

Oncology submission

For oncology diagnoses submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) and select Prior Authorization and Notification.
Alternatively, call the oncology prior authorization number 888-397-8129.

Procedure code PA listing (partial)

Codes requiring prior authorization or special billing notes (partial list):

Examples

A9278 (listed in procedural/device entries).
14020, 14021 (cosmetic codes) — noted to be billed with skin cancer diagnoses when applicable (Prior Authorization Effective Date example July 1, 2021).
15820, 15822, 15823 (reconstructive/scar revision‑type codes) — example entry with Prior Authorization Effective Date = Jan. 1, 2015.

Document contains numerous additional CPT and HCPCS codes with PA entries and notes; this is a partial extract and full code lists and notes are in the source document.

Partial coverage criteria from section

Selected coverage/authorization requirements and effective dates for items listed in this section.

DME: prior authorization required only for the codes listed when retail purchase or cumulative rental cost exceeds $500 (examples include A9900, E0637, E0465).

FESS (Functional Endoscopic Sinus Surgery) codes (e.g., 31253, 31259, 31240, 31255, 31257) require prior authorization (Prior Authorization Effective Date = July 1, 2018).

Gender dysphoria treatment and certain genetic testing CPTs (e.g., 81163, 81164, 81520) require prior authorization; Gender Dysphoria Treatment PA effective Jan. 1, 2018/2019 and PA required for these codes with any diagnosis.

Some DME/K‑series codes (e.g., K0856–K0860) and other device groups are listed with PA requirements and effective dates in the document; refer to the full listing for specifics.

Prior authorization / notification criteria (partial)

Services and codes require prior authorization or notification as listed; some authorizations limited to outpatient settings.

Genetic and molecular testing (e.g., CPTs 87505, 87506, 87507 and related codes) require prior authorization/notification when performed in an outpatient setting; the authorization/notification process requires indicating the laboratory and test name and payment is authorized only for CPTs registered with the Genetic and Molecular Testing Prior Authorization/Notification Program (Prior Authorization Effective Date example Nov. 1, 2020).

BRCA testing (examples 0111U, 0129U): notification/prior authorization required before DNA sequencing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Home health care prior authorization: prior authorization required only in outpatient settings, including the member's home (effective dates noted in the document).

Injectable medications and biologics: numerous J‑codes require prior authorization (examples listed); Review at Launch for New to Market Medications policy applies and pre‑determination is highly recommended (examples include multiple J‑codes with effective date April 1, 2024).

Prior authorization code lists and notes

Codes listed below require submission of prior authorization as indicated; effective dates provided where specified.

Orthognathic surgery examples

CPT range examples 21121–21159 listed under orthognathic surgery and require prior authorization per table entries.
Numerous orthotics/prosthetics HCPCS L‑codes are listed and require prior authorization; effective dates include Jan. 1, 2015; May 1, 2019; Apr. 1, 2019 in various rows.

The section includes extensive L‑code lists (e.g., L0170, L0462, L0480, L0624, L0631, L0634, L0637, etc.) with prior authorization requirements; providers must follow the listed submission instructions.

Coverage notes (partial)

Partial coverage/authorization guidance for listed codes and services in this section.

Many therapy and evaluation CPT codes are referenced with guidance on submission via the UnitedHealthcare Provider Portal; some codes are noted as not requiring prior authorization for DME providers or are marked with an asterisk to indicate PA not required.*

Advanced outpatient imaging and other services may require prior authorization only when requested in an outpatient hospital setting; check the table rows for site‑of‑service notes.

Rhinoplasty, septoplasty and sinuplasty entries include prior authorization effective dates (e.g., Jan. 1, 2015; July 1, 2018) and additional information fields in the table.

Prior authorization and site-of-service review

Prior authorization requirement and review notes for specified procedure codes:

Spine procedures (examples CPTs 22510, 22512, 22515 and related codes): prior authorization is required and site of service will be reviewed as part of the prior authorization process; effective dates and cross‑mappings are provided in the table rows.

Multiple spine‑related CPTs listed across rows indicate prior authorization is required; providers should expect site‑of‑service review during the PA.

Prior authorization criteria by service group

Listed services require prior authorization; some entries note site-of-service review or specific case-management contacts.

Spine procedures

CPTs 22510, 22512, 22515 (and related codes listed) — prior authorization required; site of service will be reviewed as part of the prior authorization.

Ventricular Assist Device (VAD) services (examples 33927, 33929, 33975): prior authorization/notification required; initiation instructions direct providers to call the notification number on the member's health plan ID and fax required forms to Optum VAD Case Management (855‑282‑8929).

Transplant and CAR T‑cell therapy services (examples Q2056, Q2055, Q2053, J3490, J9999, 0537T–0539T): prior authorization is required; contact the State Transplant Case Management Team at 888‑936‑7246 for transplant/CAR‑T coordination per the table notes.

Wound VAC (E2402) entries: prior authorization required (Prior Authorization Effective Date = Jan. 1, 2015) and additional instructions are referenced in the document.

Observed prior-authorization code rows

Prior authorization mapping rows observed in this partial extract:

Wound VAC (E2402): code rows repeatedly show E2402 with a Prior Authorization Effective Date of Jan. 1, 2015; additional information/how to obtain prior authorization fields are present in the table.

Observed cardiac-related code rows

Cardiac-related rows observed:

Cardiac device/procedure entries list codes Q0508 and Q0509 (and related phrases referencing restoration of normal blood flow to a ventricle of the heart) and include prior authorization fields in the table rows.

The cardiac entries in the extract include code identifiers Q0508/Q0509 and reference prior authorization indicators; additional information fields are present but may be blank in this partial extract.

Prior authorization requirement for listed codes

Coverage actions noted in this part specify that prior authorization is required for the listed wound vac items and procedure codes with stated effective dates.

Prior authorization is required for wound vac items and procedure codes listed in the table (examples: E2402, Q0507, 33975, 33976, 33979, 36475, 36478, 37700, 37780).

Effective dates shown in various rows include Jan. 1, 2015 and April 1, 2017 for wound vac and related procedure entries; providers should use the table rows to confirm the effective date for each code.

How Providers Submit Requests and Required Actions

Prior Authorization

How to submit prior authorization requests

Prior authorization is required for many specific procedures, devices, implants, testing and treatments. Providers must submit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com → Prior Authorization and Notification), by phone at 877-842-3210, or by fax at 877-940-1972. For oncology diagnoses, submit requests online via the Provider Portal or call 888-397-8129. Prior authorization is not required for emergency or urgent care. Out-of-network requests must be submitted by an in-network provider, except for emergent or urgent care.

Online: UHCprovider.com → Sign In → Prior Authorization and Notification
Phone: 877-842-3210
Fax: 877-940-1972

Note

Behavioral health referrals

Many plans route behavioral health benefits through a designated behavioral health network. When referring for mental health or substance use services, call the behavioral health intake number.

Behavioral health referrals: call 888-887-9003

Prior Authorization

Service- and code-specific prior authorization

Prior authorization is required for numerous service- and code-specific procedures. Examples include bariatric surgery, breast reconstruction, cochlear and auditory implants, joint replacement, select cardiology and radiology services, and many injectable medications. Providers should verify code-level requirements and effective dates prior to scheduling.

Examples of services requiring PA: bariatric surgery (e.g., 43644–43848 series; effective dates vary)
Breast reconstruction and related mastectomy/reconstruction codes (see Provider Portal guidance)
Cochlear and auditory implants (e.g., 69729–69930; cochlear implants effective Mar. 1, 2023)
Joint replacement and major orthopedic procedures (multiple CPTs listed; PA effective Jan. 1, 2015 for many)
Injectable chemotherapy and many biologic/infusible drugs require PA when administered outpatient

Prior Authorization

How to submit oncology prior authorization requests

Submit oncology prior authorization requests online using the UnitedHealthcare Provider Portal. If needed, contact the oncology prior authorization phone number for assistance.

Oncology requests: UHCprovider.com → Prior Authorization and Notification
Or call: 888-397-8129

Prior Authorization

Examples of services requiring prior authorization

Certain procedures, devices and supplies require prior authorization — including many orthotics/prosthetics L-codes, wound VAC supplies, DME above cost thresholds, cardiac devices, stimulators, transplant and CAR T-cell therapies, and specific surgical CPTs. Providers must confirm PA requirements and effective dates for the specific code(s) and submit via the Provider Portal or applicable specialty phone numbers.

Durable medical equipment (DME): PA required only for listed codes with a retail purchase or cumulative rental cost > $500; prosthetics are not DME — see orthotics/prosthetics lists (effective dates vary)
Orthotics & prosthetics: extensive L-code list requires PA (effective dates include Jan. 1, 2015; Apr. 1, 2019; May 1, 2019; Mar. 1, 2016)
Wound VAC (E2402): prior authorization required; prior authorization effective date = Jan. 1, 2015
Stimulator/device implantation (neurostimulators, implantable stimulators, related codes): PA required; many codes effective Jan. 1, 2015 and later
Cardiac devices/procedures (Q0508, Q0509 and related codes): PA indicators present — verify specific code guidance
Transplants and CAR T‑Cell therapy: PA required; contact State Transplant Case Management Team at 888-936-7246 for assistance

Prior Authorization

Procedure codes and PA notes (partial)

A non-exhaustive set of procedure, functional/physiologic and reconstructive/cosmetic codes are listed in the Provider Portal and require prior authorization or notification. This includes many musculoskeletal, integumentary, arthroscopic, spine, nervous system, ophthalmologic, upper GI, urologic and vein procedure CPTs. Site-of-service review may be performed as part of PA for certain procedures (for example spine codes).

Functional/physiologic and reconstructive codes (examples): 17108, 17999, 21137–21295 series, 21740, 21742, 28344, 15820, 15823 (effective dates vary)
Musculoskeletal/orthopedic and arthroscopic codes (examples): 27120–27138 series, 27412, 27447, 27486–27487, many 28000–28300 series codes (PA required for listed codes)
Spine procedures: numerous 22100–22533 and 22510–22515 related codes; PA required and site-of-service reviewed
Radiology/advanced imaging: specified codes require notification/PA (see Provider Portal; some effective dates Jan. 1, 2015 and later)

Prior Authorization

Genetic and BRCA testing prior authorization/notification

Genetic and molecular testing performed in outpatient settings requires prior authorization. Providers must follow the authorization/notification process which includes identifying the performing laboratory and the specific test. BRCA testing requires notification/prior authorization before DNA sequencing is performed; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Genetic & molecular testing PA effective Nov. 1, 2020 for many CPTs (e.g., 87505–87507 and listed proprietary U-codes)
BRCA testing: notification/prior authorization required prior to DNA sequencing; ordering provider must notify the lab and the lab will notify UnitedHealthcare
Authorization/notification must include laboratory name and exact test to be performed

Prior Authorization

Gender dysphoria and genetic testing prior authorization

Gender dysphoria treatment codes and associated genetic testing codes require prior authorization. Providers should verify the code list and effective dates in the Provider Portal before initiating treatment.

Gender dysphoria treatment codes include 81520, 81163–81164 (PA effective Jan. 1, 2018/2019 depending on code)
Prior authorization is required for these codes regardless of diagnosis

Prior Authorization

Transplants and CAR T‑Cell therapy prior authorization

Transplant and CAR T‑cell therapy services require prior authorization. Contact the UnitedHealthcare Community/State Transplant Case Management Team to initiate authorization and care coordination.

Transplants: PA required (e.g., unclassified code C9399/J3490 entries; effective April 1, 2024)
CAR T‑cell therapies and related codes (Q2056, Q2053, Q2055 and proprietary drug/car‑T codes): PA effective dates vary (see portal); call State Transplant Case Management Team at 888-936-7246

Prior Authorization

Stimulator/device implantation prior authorization

Prior authorization is required for implantation of electrical stimulation and neurostimulator devices, and for other implantable stimulators. Many of these codes and related L-codes have effective PA dates beginning Jan. 1, 2015 and later — check the Provider Portal for the full list and PA submission instructions.

Neurostimulator and stimulator implantation codes and L-codes (example entries and effective dates listed in Provider Portal)
Implantation procedures: verify exact CPT/HCPCS and effective PA date before scheduling

Prior Authorization

Wound VAC prior authorization

Wound VAC supplies and related billing codes (notably E2402) require prior authorization. The prior authorization effective date for Wound VAC (E2402) entries is Jan. 1, 2015. Providers should call the notification number on the member's ID or submit via the Provider Portal according to the PA instructions.

Wound VAC code: E2402 — PA required, effective Jan. 1, 2015
Submit Wound VAC PA via Provider Portal or follow notification instructions; verify effective dates and ancillary billing guidance

Definitions and Key Policy Notes

inv-69: Prior authorization definition — Prior authorization requests are approvals requested before providing non-emergent services; not required for emergency or urgent care.

DefinitionPrior authorization requests are approvals requested before providing non-emergent services; not required for emergency or urgent care.

Submission MethodsRequests may be submitted online via the UnitedHealthcare Provider Portal, by phone (877-842-3210), or by fax (877-940-1972).

Out-of-network noteOut-of-network requests must be made by an in‑network provider except for emergent or urgent care.

inv-70: Behavioral health network definition — Designated behavioral health network for mental health and substance use service referrals.

DefinitionDesignated behavioral health network for mental health and substance use service referrals; call 888-887-9003 when referring.

UseMany benefit plans provide behavioral health services through this network; providers should contact the number on referrals guidance.

inv-71: Provider portal definition — UHCprovider.com Provider Portal (Prior Authorization and Notification).

DefinitionUnitedHealthcare Provider Portal (UHCprovider.com) — portal used to submit Prior Authorization and Notification requests online.

How to accessGo to UHCprovider.com, Sign In, then select Prior Authorization and Notification on the Provider Portal dashboard.

inv-72: PA submission note — Additional Information/How to obtain Prior Authorization.

Submission noteAdditional Information/How to obtain Prior Authorization fields provide specific instructions per service (e.g., indicate laboratory and test name for genetic testing); follow the listed process for each code entry.

ExamplesCosmetic codes note billing with skin cancer diagnoses; genetic testing entries require authorization/notification process details.

Where to find formsFax form for PA is available at UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources > Prior Authorization Forms.

inv-73: Prosthetics vs DME — Prosthetics are not DME.

DistinctionProsthetics are explicitly noted as not being DME in the DME section (see orthotics and prosthetics).

ImplicationProsthetics follow orthotics/prosthetics prior authorization rules, not the DME retail/rental $500 threshold rules.

inv-74: Gender Dysphoria Treatment PA requirement — Prior authorization required for gender dysphoria treatment codes with any diagnosis code.

RequirementPrior authorization is required for Gender Dysphoria Treatment codes; prior authorization is required for these codes with any diagnosis (PA Effective Dates noted: Jan. 1, 2018 and Jan. 1, 2019).

Example CodesCodes listed in this category include 81520, 81163, 81164 (per Gender Dysphoria Treatment entries).

inv-75: Genetic and Molecular Testing Program — A program requiring providers to indicate laboratory and test name; labs and ordering providers must follow notification/prior authorization procedures.

ProgramGenetic and Molecular Testing Prior Authorization/Notification Program requires providers to indicate the laboratory and test name during authorization/notification.

Payment conditionPayment will be authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program.

BRCA processBRCA testing requires notification/prior authorization before DNA sequencing; ordering provider must notify the lab and the lab will notify UnitedHealthcare.

inv-76: Review at Launch for New to Market Medications — UnitedHealthcare policy used to manage medications newly approved by the FDA.

PolicyReview at Launch for New to Market Medications — UnitedHealthcare policy referenced for managing medications newly approved by the FDA; providers should check this policy for up-to-date inclusion and pre-determination is highly recommended.

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

inv-77: Prior authorization requirement (orthotics/prosthetics) — Prior authorization required for orthotic and prosthetic retail purchases or cumulative purchases.

RequirementPrior authorization is required for orthotic and prosthetic retail purchases or cumulative purchases as specified in the orthotics and prosthetics section.

ExamplesL-series HCPCS codes (e.g., L1812, L1830, L1832, L3763) are listed in the orthotics and prosthetics section and require PA when thresholds are met.

Effective DatesSome entries include Prior Authorization Effective Dates (examples: May 1, 2019; April 1, 2019).

inv-78: Proton Beam Therapy definition — Proton Beam Therapy: Focused radiation therapy using beams of protons.

DefinitionProton Beam Therapy: focused radiation therapy using beams of protons.

Example CodesExample CPT codes associated with proton beam therapy include 77520 and 77523 (listed in the Proton Beam Therapy entry).

PA Effective DatePrior authorization effective date entries for proton beam therapy appear in the listing (example: Jan. 1, 2015 for related entries).

inv-79: Site of Service - outpatient hospital — Prior authorization only required when requesting service in an outpatient hospital setting (contextual note).

DefinitionSite of Service (SOS) - outpatient hospital: Prior authorization only required when requesting service in an outpatient hospital setting for the listed codes.

ScopeApplies to multiple service categories (e.g., Auditory System, Cardiovascular System, Cataract Surgery) as shown in the SOS outpatient hospital section.

inv-80: Site-of-service review — site-of-service review

DefinitionSite-of-service review: site of service will be reviewed as part of the prior authorization for certain procedures (e.g., spine surgeries).

ApplicationUsed to determine appropriate setting and authorization requirements during PA for listed procedure codes.

inv-81: Optum VAD Case Management Team contact — Optum VAD Case Management (VAD prior-authorization contact).

ContactOptum VAD Case Management — contact for VAD prior-authorization notifications; fax form provided by nurse to Optum VAD Case Management per instructions.

ProcessCall 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 (per section instructions).

inv-82: State Transplant Case Management Team contact — State Transplant Case Management Team (transplant/CAR-T notification contact).

ContactState Transplant Case Management Team — contact for transplant and CAR-T notification: 888-936-7246.

UseProviders should contact the State Transplant Case Management Team for prior authorization/notification related to transplant and CAR T-Cell therapy services.

inv-83: Prior Authorization Effective Date — Prior Authorization Effective Date: the date shown in table rows indicating when prior authorization requirement became effective (e.g., Jan. 1, 2015).

DefinitionPrior Authorization Effective Date: the date shown in table rows indicating when the prior authorization requirement became effective (example: Jan. 1, 2015 for Wound Vac entries).

ExampleWound Vac (E2402) entries show a Prior Authorization Effective Date of Jan. 1, 2015 in multiple rows.

inv-84: Code identifier — Code identifiers (e.g., E2402, Q0508, Q0509) as presented in the table.

IdentifierCode identifiers appear in the table for device/procedure mapping (examples shown include E2402, Q0508, Q0509).

UsageThese identifiers are used to match prior authorization rules to specific devices/procedures in the listing (e.g., E2402 = Wound Vac).

inv-85: Wound Vac definition — Wound Vac (negative pressure wound therapy items/procedures).

DefinitionWound Vac: negative pressure wound therapy items/procedures; code identifier E2402 is used in the listing.

PA Effective DateWound Vac (E2402) entries show Prior Authorization Effective Date = Jan. 1, 2015 in multiple rows.

NoteAdditional Information/How to obtain Prior Authorization fields are present for Wound Vac entries in the table (excerpts show blank instruction fields in the extract).

97024	Application of a modality to one or more areas; diathermy (includes ultrasound)
97032	Application of a modality to one or more areas; electrical stimulation (manual)
97035	Application of a modality to one or more areas; ultrasound, each 15 minutes
97036	Application of a modality to one or more areas; Hubbard tank
97139	Unlisted modality (identify modality)
97150	Therapeutic procedures, group (2 or more individuals)
97164	Physical therapy evaluation, moderate complexity
97168	Therapeutic procedure, direct (one-on-one) contact by the provider; neuromuscular reeducation
97530	Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
97535	Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training), each 15 minutes

T1000-T1003	Private duty nursing services range (routine, continuous, etc.)
T1002	RN or LPN services, up to 15 minutes

OpenPayer

Prior Authorization Requirements for Texas CHIP

Coverage and Prior Authorization Criteria

Code Lists and Identifiers

How Providers Submit Requests and Required Actions

Definitions and Key Policy Notes