CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas

Lists prior authorization requirements, code groups, submission methods, contacts, and thresholds for UnitedHealthcare Connected (Medicare-Medicaid Plan) providers in Texas for inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas

Policy CodePolicy N/A

Change TypeMinor/No material change

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, chat, or fax to 877-940-1972.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplecoded services requiring prior authorization (various specialties)

online/chat/faxsubmission methods for prior auth

regardless of billed amountflat prior auth rule for listed device codes

multipleDME/device codes requiring prior authorization

855-851-1127

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naviHealth Continued Care program contact

Services and Prior Authorization Criteria

Post-acute inpatient service entries (fragment)

Post-acute inpatient services require prior authorization and/or notification for specified procedures, facility types, and codes. Submit prior authorization requests through the Continued Care program (naviHealth) or contact the numbers provided below. Exceptions and effective dates are noted where available.

Joint replacement (total hip and knee): codes include 23470-23472, 24360-24363, 26340, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27412. Prior authorization/notification required. Effective date: Jan. 1, 2015.

Notification and prior authorization required for post-acute inpatient services provided by: acute care hospitals; acute inpatient rehabilitation; critical access hospitals; long-term acute care hospitals; skilled nursing facilities. Submit requests through naviHealth (Continued Care program). Phone: 855-851-1127. Fax: 844-244-9482.

Continued Care Program overview: leverages technology and care coordination to support members from acute discharge through return home.

Skilled nursing facility prior authorization exception: UnitedHealthcare Assisted Living Plans (HMO SNP, HMO-POS SNP, PPO SNP) and UnitedHealthcare Nursing Home Category are excluded from the SNF prior authorization requirement.

Orthotics and related codes: Orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000 require prior authorization.

Therapy services: Prior authorization is required for re-evaluations and specified therapy/rehabilitation codes; initial evaluations generally do not require prior authorization. Some therapy codes and dates have specific effective dates (see coding lists).

Specific procedure/codes with contact requirements: Ventricular Assist Device (VAD) and related mechanical pump procedures (codes 33927-33929, 33928, 33975-33983) require prior authorization/notification; contact Optum/UnitedHealthcare VAD Case Management or call the number on the member's ID card. VAD management phone numbers referenced: 855-282-8929 and other program contacts.

Vascular procedures (saphenous vein ablation/related): codes include 36473, 36475, 36476, 36479 and others for ablation/removal of main trunks and named branches of the saphenous veins. Prior authorization applies; some entries note effective dates (e.g., Oct. 1, 2018; Jan. 1, 2015).

Neurostimulator/device implantation: codes include L8682-L8683 and other implant codes; prior authorization effective date July 1, 2021 (where noted).

Durable Medical Equipment (DME) and prosthetics referenced in post-acute context: many HCPCS codes (L*, K*, E* series) are subject to prior authorization regardless of billed amount or when cumulative rental exceeds $1,000; various effective dates (examples shown: July 1, 2017; July 1, 2021).

Radiology and advanced imaging: care providers ordering advanced outpatient imaging procedures are responsible for prior authorization where applicable; some effective dates noted (e.g., Jan. 1, 2020; Jan. 1, 2021).

CAR T-cell, cellular and transplant therapies: select codes/devices (Q2054, Q2053, C9399, J3590, J3393, J3490 and related) require prior authorization and case management; contact Community and State Transplant Case Management at 888-936-7246 for transplant/CAR T-cell management and certain cellular therapies (effective dates noted for specific products).

Psychological testing codes (e.g., 96116, 96121) require prior authorization effective Oct. 1, 2019; some psychological testing entries reference date-based applicability (e.g., March 1, 2022).

Procedure-specific notes: many fragmented entries indicate prior authorization effective dates, code groupings, and that initial evaluations often do not require authorization while re-evaluations do. Providers should use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool where directed.

Claims and coding note: CPT and HCPCS code lists in this section are extensive and fragmented; providers must reference the full payer coding lists or portal for complete, current code sets and any member-specific exceptions.

Submission guidance: Submit prior authorization requests via naviHealth for Continued Care program cases, or via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool when specified. For device or transplant case management, use the phone numbers listed above.

Provider action callout: Prior Authorization & Notification Required (see items).

Code Lists and Coding Rules

Cardiac / Cardiovascular CPT examples (93350–93460 range)CPTCovered

93350	Echocardiography, transesophageal, image(s)/Doppler
93351	Echocardiography, transesophageal, with additional procedures
93460	Catheter placement, coronary

Cardiac / Cardiovascular CodesCPTCovered

37230	Embolization or occlusion of vessel; initial vessel
37231	Embolization, additional vessel

Reconstructive / Cosmetic Surgery CodesCPTCovered

19316

Mastectomy-related reconstructive procedure example

Durable Medical Equipment (DME) ExamplesHCPCSCovered

E0328

Standard wheelchair

Category III / Other CPT ExamplesCPT

0054T	Category III — example interventional procedure
0055T	Category III — related add-on
0100T	Category III
0101T	Category III
0102T	Category III
0106T	Category III
0107T	Category III
0108T	Category III
0109T	Category III
0110T	Category III

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Injectable Medications (J-codes)HCPCSCovered

J3247	Cosentyx IV
J2267	Omvoh
J1576	Panzyga

Procedure / Device groups requiring prior auth or notificationmixedCovered

23470	Total shoulder arthroplasty (example joint replacement)
27130	Total hip arthroplasty
27412	Total knee arthroplasty

Therapy and Psychological Testing Codes (examples)CPTCovered

97112	Therapeutic procedure, neuromuscular reeducation
97139	Unlisted therapeutic procedure (used for group activities)
97164	Physical therapy re-evaluation (note: re-evaluations require prior authorization per policy)
97530	Therapeutic activities
97535	Self-care/home management training
97755	Assistive technology evaluation
G0152	Nursing facility—therapy

Spinal Surgery and Fusion ExamplesCPT

22100	Hemilaminectomy, single vertebral segment
22526	Arthrodesis, posterior or posterolateral technique
22808	Placement of interbody biomechanical device (example)

Neurosurgery / Craniotomy ExamplesCPT

63012	Laminectomy with decompression of nerve root
64568	Insertion or replacement of neurostimulator electrode array

Transplant / CAR T Drug Codes (examples)HCPCS

J3392	Transplant-related drug (example)
C9399	Unclassified drugs and biologics (used for CAR-T billing)
J3590	Unclassified biologics

Inpatient / Post-Acute Procedure Codes (examples)CPTCovered

23470	Total shoulder arthroplasty
27130	Total hip arthroplasty
27412	Total knee arthroplasty
36475	Saphenous vein ablation
33983	Heart transplant (example)
61888	Vagus nerve stimulation implant
64569	Insertion or replacement of neurostimulator lead
38209	Bone marrow or stem cell harvest
38210	Bone marrow or stem cell transplant infusion
50365	Nephrectomy procedure example

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Referenced CPT codes (fragment examples)CPT

36475	Ablation of main trunks (repeated in source)
36473	Removal/ablation of saphenous veins (repeated)
97112	Therapeutic procedure (referenced)
97139	Unlisted therapeutic procedure (referenced)

How to Submit and Authorization Steps

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (One Healthcare ID). Requests may also be submitted via 24/7 chat on the Contact Us page or by fax to 877-940-1972. Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by a network care provider.

Portal: UHCprovider.com → Sign In (One Healthcare ID) → Prior Authorization and Notification tab
Chat: 24/7 via the Contact us page
Fax: 877-940-1972
Emergency/urgent care: no prior authorization required
Out-of-network requests: must be submitted by a network care provider

Prior Authorization

Route prior authorization for incontinence supplies

Incontinence supplies require prior authorization through the service coordinator when not provided by Tenderheart Health Outcomes. To obtain supplies from Tenderheart, call 866-295-2319; to obtain supplies from other providers contact the service coordinator at 800-349-0550.

Terms and Program Definitions

Prior authorization — definition

DefinitionPrior authorization — A review process requiring providers to obtain approval before delivering certain services; requests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, via 24/7 chat, or by fax to 877-940-1972. Prior authorization is not required for emergency or urgent care.

Submission methodsOnline portal, 24/7 chat, or fax (877-940-1972).

Out-of-network ruleOut-of-network requests must be made by a network care provider.

Continued Care program (naviHealth)

Program nameContinued Care program (naviHealth).

PurposeLeverages technologies and care coordination to support members through the post-acute journey from discharge to return home.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas

Policy CodePolicy N/A

Change TypeMinor/No material change

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, chat, or fax to 877-940-1972.

SourceLink

On This Page

Tenderheart Health Outcomes supply requests: 866-295-2319
Other providers/service coordinator: 800-349-0550

Prior Authorization

Prior authorization required for many prosthetics and DME

Prior authorization is required for many prosthetics and certain DME codes (examples include E0766, E2617, E2609, E8001) regardless of billed amount; multiple entries indicate effective dates (e.g., July 1, 2021 and Jan. 1, 2015) for specific codes.

Example prosthetic/DME codes requiring prior authorization regardless of billed amount: E0766, E2617, E2609, E8001
Some entries reference effective dates such as July 1, 2021 and Jan. 1, 2015

Prior Authorization

Post-acute inpatient prior authorization and notification via naviHealth

Prior authorization and notification of the admission date are required for post-acute inpatient services (including joint replacement post-acute settings). Submit requests through naviHealth as part of the Continued Care program.

Submit prior authorization requests through naviHealth (Continued Care program)
Phone: 855-851-1127
Fax: 844-244-9482
Applies to acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, and skilled nursing facilities

Prior Authorization

Prior authorization for listed DME and device HCPCS codes

Numerous durable medical equipment and device HCPCS codes listed require prior authorization regardless of billed amount; effective dates are noted for many specific codes in the DME/device lists.

Prior authorization required regardless of billed amount for many listed DME/device HCPCS codes
See DME code lists (E- and K-codes, L-codes, etc.) in the policy for specific codes and effective dates

Documentation Required

DME rental cost threshold for prior authorization

A cumulative rental cost threshold applies to DME: prior authorization is required when cumulative rental cost is more than $1,000.

Threshold: cumulative rental cost > $1,000 triggers prior authorization

Prior Authorization

Prior authorization and notification for post-acute inpatient admissions

Notification of admission date and prior authorization are required for listed post-acute inpatient admissions (e.g., joint replacement, transfers from acute care to post-acute settings). Submit requests through naviHealth as part of the Continued Care program.

Submit via naviHealth (Phone: 855-851-1127; Fax: 844-244-9482)
Applies to transfers to acute inpatient rehabilitation, LTAC, SNF and similar post-acute settings
Certain UnitedHealthcare Assisted Living Plans are excluded from SNF prior authorization requirement

Prior Authorization

Therapy service prior authorization rules (re-evaluations required)

Prior authorization is required for therapy re-evaluations and for many therapy CPT/HCPCS codes listed; initial therapy evaluations generally do not require prior authorization (some therapy entries note exceptions for nursing facilities).

Prior authorization required for all re-evaluations and specified therapy codes (examples: 97139, 97164*, 97530, 97755)
Initial evaluations do not require prior authorization in general
*Some codes: prior authorization not required for nursing facilities

Prior Authorization

Ambulance transport prior authorization and TX mandate

Air and ground ambulance transports have prior authorization effective dates noted; the Texas mandate applies to certain ground ambulance HCPCS codes with an effective date of April 1, 2016.

Air ambulance prior authorization effective date: Jan. 1, 2015 (air transport entries)
Ground ambulance TX mandate codes include A0422, A0425, A0428, A0434, A0382 and related entries
Ground ambulance TX mandate effective date: April 1, 2016

Prior Authorization

Orthotics and prosthetics prior authorization threshold

Prior authorization is required for orthotics and prosthetics listed when provided as a retail purchase or when the cumulative rental cost exceeds $1,000; many L-codes are listed with this requirement.

Threshold: retail purchase or cumulative rental cost > $1,000 triggers prior authorization for prosthetic/orthotic codes
Multiple L-codes (orthotics/prosthetics) in the policy are subject to this rule

Prior Authorization

Prior authorization for potentially unproven services (effective dates apply)

Certain potentially unproven services and specific procedure codes have prior authorization effective dates (for example, some entries show an effective date of April 1, 2023).

Example: Potentially Unproven Services entry shows Prior authorization effective date = April 1, 2023

Prior Authorization

Contact for transplant and CAR T prior authorization

For transplant and CAR T-Cell therapy services (including specified CAR-T products), providers must contact the Community and State Transplant Case Management team for prior authorization.

Contact Community and State Transplant Case Management team at 888-936-7246
Or call the notification number on the back of the member's health plan ID for authorization

Prior Authorization

Psychological testing and radiology prior authorization notes

Psychological testing codes (e.g., 96116, 96121 and related codes) and certain radiology entries have prior authorization notes and effective dates (for example, 96116 prior authorization effective Oct. 1, 2019).

Psychological testing: 96116 and 96121 — prior authorization effective Oct. 1, 2019
Radiology: advanced outpatient imaging procedures have prior authorization effective dates (e.g., Jan. 1, 2021) and ordering providers are responsible for providing authorization/notification

Prior Authorization

Prior authorization for stimulators and neurostimulator implantation

Implantation and neurostimulator device codes (examples include L8682, L8683, E0747, E0748) are listed with prior authorization effective dates (e.g., July 1, 2021 and earlier) and require prior authorization for the specified services.

Neurostimulator/device L-codes (e.g., L8682, L8683) show prior authorization effective date July 1, 2021
Other related CPT/HCPCS device entries include prior authorization effective dates (various years)

Prior Authorization

Call notification number for authorization of listed inpatient/post-acute procedures

For listed inpatient/post-acute procedures such as Ventricular Assist Devices (VAD), vein procedures and vagus nerve stimulation, providers must call the notification number on the member's ID card and contact the Optum VAD Case Management/management team as instructed for prior authorization; a nurse-provided fax form may be required.

Codes listed include VAD and related device/procedures (examples: 33927, 33928, 33929, 33975–33983, 36473–36479, 37735, 37766, 37785, 64569, 61888, C1767, L8681, L8689)
Call the notification number on the back of the member's health plan ID card
Optum VAD Case Management team phone: 855-282-8929
Fax the form provided by the nurse to the management team as instructed

Prior Authorization

Authorization contact for inpatient post-acute services affecting blood flow

Prior authorization is required for listed inpatient post-acute service entries that restore or affect blood flow (codes shown in the section). Contact the management team at 855-282-8929 for prior authorization.

Examples of codes in this group: 33983, 36475, 36473, 37765
Authorization/contact phone: 855-282-8929

Submission route and contactsSubmit prior authorization requests through naviHealth as part of the Continued Care program. Phone: 855-851-1127; Fax: 844-244-9482.

Continued Care program (naviHealth) — duplicate entry

Program name (duplicate)Continued Care program (naviHealth).

Use caseRequired submission path for post-acute inpatient prior authorization and admission notification for listed settings (acute care hospitals, inpatient rehab, LTAC, SNFs, etc.).

ContactPhone: 855-851-1127; Fax: 844-244-9482.

Retail purchase or cumulative rental cost > $1,000 — threshold definition

Threshold statementRetail purchase or cumulative rental cost greater than $1,000 requires prior authorization for orthotics/prosthetics and related device codes.

Typical code examplesL-codes and prosthetic HCPCS (e.g., L3020, L8042, L8499, L8609, L8629, etc.) listed in the post-acute orthotics/prosthetics entries.

Where appliedNoted in the Inpatient Admissions Post-Acute Services orthotics/prosthetics sections and related additional information lines.

Psychological Testing — definition and code examples

DefinitionPsychological Testing — Includes CPT/HCPCS test administration and scoring codes such as 96116 and 96121 (and related series 96130–96137).

Prior authorization notesCode 96116 prior authorization effective Oct. 1, 2019; entries indicate when prior authorization will or will not be required per date and circumstance.

Code examples96116, 96121, 96130, 96131 (and other related psychological testing codes referenced).

Stimulators / Neurostimulator — definition

DefinitionStimulators / Neurostimulator — Implantation and related device codes for devices that send electrical impulses (neurostimulator/stimulator devices).

Code examplesL8682, L8683 and other stimulator device codes; CPT/HCPCS implantation and neurostimulator procedure codes referenced with effective dates.

Prior authorization noteEntries indicate prior authorization effective dates (e.g., July 1, 2021) for certain neurostimulator services.

Ventricular Assist Device (VAD) — definition

DefinitionVentricular Assist Device (VAD) — A mechanical pump that takes over the function of the damaged ventricle of the heart and related VAD procedure/device codes require prior authorization and special notification.

Code examples33927, 33928, 33929, 33975, 33976, 33982, 33983 (VAD/mechanical pump procedure codes).

Prior authorization actionsProviders must call the notification number on the member's ID card and contact management/Optum VAD Case Management (855-282-8929) and fax nurse-provided form as instructed.

Vagus Nerve Stimulation (VNS) — definition

DefinitionVagus Nerve Stimulation (VNS) — Implantation of a device that sends electrical impulses into one of the cranial nerves; device and procedure codes listed require prior authorization where noted.

Code examples64569, 61888, C1767, C1778, L8681, L8689 (VNS procedure/device codes listed).

Effective dateSome entries reference an effective date of Jan. 1, 2015 for VNS prior authorization requirements.

mechanical pump / ventricular assist device — definition (alternate)

DefinitionMechanical pump / Ventricular Assist Device — A mechanical pump that takes over the function of the damaged ventricle; related codes and procedures listed under VAD/mechanical pump require prior authorization and provider notification.

Code examples33975, 33976, 33982, 33983 (mechanical pump/VAD codes referenced).

Contact for authorizationOptum VAD Case Management / management team contact provided (855-282-8929) and instruction to call the notification number on the member's ID card and fax required forms.