CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana Hoosier Care Connect

A list of services and CPT/HCPCS/DME codes requiring prior authorization for participating UnitedHealthcare Community Plan of Indiana providers; includes submission methods and special notes (e.g., emergency care exception). Affects participating IN network providers and prior authorization processes.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-610-9785.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

May 1, 2025effective date

Phone & onlinesubmission methods provided

Exemptemergency/urgent care

Manyitems requiring prior authorization (partial)

50+injectable medication codes listed

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 Requiring Prior Authorization

Prior authorization coverage criteria (partial)

Specific services and associated CPT/HCPCS codes require prior authorization. Examples shown below are partial and illustrative from the document segment.

Covered when prior authorization is obtained before the service is provided (prior authorization is not required for emergency or urgent care).

ONE OF

Bariatric surgery CPT/HCPCS codes listed (examples include 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842–43848) — prior authorization required; some plans have Center of Excellence requirements and some obesity-related services may not be covered by certain plans.
BRCA genetic testing CPT codes listed (examples include 81162–81166, 81212) — prior authorization required.
Cochlear implant procedure and device codes listed (examples include 69930, L8615–L8619, L8627–L8628) — prior authorization required.
Durable medical equipment (DME) codes listed (examples include A9279, A9999, E0265) — prior authorization required when retail purchase or cumulative rental cost exceeds $500.

Behavioral health services: many benefit plans provide coverage through a designated behavioral health network; authorization requirements vary by plan.

Genetic testing notification/prior authorization

Genetic and molecular testing for listed CPT codes requires registration with the Genetic and Molecular Testing Prior Authorization/Notification Program; notification/prior authorization is required for BRCA testing before DNA sequencing is performed.

The laboratory and ordering health care professional must be registered with the Genetic and Molecular Testing Prior Authorization/Notification Program for each specified genetic test.

Notification/prior authorization is required for BRCA testing before DNA sequencing is performed; the ordering health care professional must notify the laboratory conducting the test.

Genetic testing CPT codes subject to the program include ranges and specific codes (examples include 81298–81319, 81321–81323, 81328, 81330, 81335, 81346, 81504, 81519, 81522); providers should follow the program registration and notification process prior to testing.

Services requiring prior authorization (enteral services, home health care, hysterectomy)

Certain services explicitly require prior authorization; examples and representative CPT/HCPCS codes are listed below.

Enteral services — prior authorization required; enteral codes and examples are listed in the policy (see enteral code ranges and mappings).

Home health care — prior authorization required (examples: G0151, G0152, G0153).

HYSTERECTOMY CODES

Hysterectomy CPT codes listed require prior authorization (examples include 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292, 58294, 59897, 58548).

Injectable medications prior authorization list

A broad list of injectable medications (J-/Q-/other HCPCS codes) require prior authorization; examples and representative codes are provided for provider submission.

Injectable medications (definition: a drug capable of being injected intravenously, subcutaneously, or intramuscularly) — prior authorization is required for the listed products and codes.

EXAMPLES OF LISTED PRODUCTS/CODES

Selected listed injectable drugs and codes include (non‑exhaustive): Actemra (J3262), Acthar (J0801), Aduhelm (J0172), Adzynma (J7171), Aldurazyme (J1931), Alyglo (J1552), Amvuttra (J0225), Avsola (Q5121), Benlysta (J0490), and others shown in the policy.
Additional examples from the policy include numerous products such as Nucala (J2182), Ocrevus (J2350/J2351), Remicade (J1745), Rituxan (J9312/J9311), Ruxience (Q5119), Soliris (J1299), and many more listed in the injectable medications sections.

Services requiring prior authorization

Prior authorization is required for the following categories and associated CPT/HCPCS codes; providers must obtain authorization or provide notification as specified prior to scheduling non-emergent services.

COVERED CATEGORIES

Occupational and physical therapy services — prior authorization required for listed CPT/HCPCS therapy codes (examples include 97012–97039, 97110–97150, 97530–97542, 97760–97799, G0281–G0283).
Advanced outpatient imaging (certain CT, MRI, MRA, PET) — notification/prior authorization required; ordering provider is responsible for notification prior to scheduling (example codes referenced: 52441, 52442).
Orthotics, prosthetics and DME items listed with retail purchase or cumulative rental cost over $500 — prior authorization required for listed codes (examples and thresholds provided in the policy).
Non-emergent air ambulance transport — prior authorization required (examples: A0430, A0431).

Relevant CPT / HCPCS / Other Codes

Injectable medications — selected HCPCS/J-codesHCPCSCovered

J3262	Actemra
J0801	Acthar
J0172	Aduhelm
J7171	Adzynma
J1931	Aldurazyme
J1552	Alyglo
J0256	Aralast NP, Prolastin-C, Zemaira
J1554	Asceniv
Q5121	Avsola
J0597	Berinert

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How Providers Must Submit and What to Do

Prior Authorization

How to submit prior authorization

This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Indiana health care professionals providing inpatient and outpatient services. Please submit your request in 1 of the following ways: - Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. To access the portal, go to UHCprovider.com and click Sign In in the top-right corner to sign in using your One Healthcare ID and password. - By phone: Call 877-610-9785 Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by a network care provider.

Note

Out-of-network request rule

Out-of-network requests must be made by a network care provider. Providers should contact UnitedHealthcare via the Provider Portal or the phone number on the member's ID card for questions about network status and submission requirements.

Prior Authorization

Enteral services prior authorization

Key Terms and Thresholds

Prior authorization overview

DefinitionPrior authorization is the approval required before providing certain inpatient and outpatient services (not required for emergency or urgent care).

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-610-9785.

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

DME prior authorization (retail/cumulative $500 threshold)

RuleDME items listed require prior authorization when the retail purchase or cumulative rental cost exceeds $500.

Example codesA9279, E0265, E0270 (policy lists multiple DME HCPCS codes)

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-610-9785.

SourceLink

On This Page

Other procedures and device categories (examples include orthognathic surgery, prosthetics/orthotics, rhinoplasty, speech therapy, maxillofacial procedures) — see policy for specific CPT/HCPCS codes and authorization instructions.

Enteral nutrition services require prior authorization. Submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by calling the number on the member's ID card.

Enteral services: Prior authorization is required.

Prior Authorization

Genetic testing prior authorization/notification

Certain genetic tests require notification or prior authorization through UnitedHealthcare's Genetic and Molecular Testing Prior Authorization/Notification Program. Notification/prior authorization is required for BRCA testing before DNA sequencing is performed; the ordering provider must notify the laboratory performing the test.

BRCA testing: Notification/prior authorization required before DNA sequencing.
Examples of CPT codes that require prior authorization/notification include: 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81307.

Prior Authorization

Home health care and hysterectomy prior authorization

Home health care and hysterectomy procedures require prior authorization. Use the Provider Portal or call the number on the member's ID card to submit requests.

Home health care: Prior authorization required. Example HCPCS: G0151, G0152, G0153.
Hysterectomy: Prior authorization required. Example CPT codes: 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292, 58294, 59897, 58548.

Prior Authorization

Injectable medications — prior authorization

Injectable medications administered IV, IM, or subcutaneously frequently require prior authorization. Submit prior authorization requests through the Provider Portal or by calling the prior authorization phone number. The following injectable drug list and associated HCPCS/J-codes require prior authorization.

Actemra — J3262
Acthar — J0801
Aduhelm — J0172
Adzynma — J7171
Aldurazyme — J1931
Alyglo — J1552
Amvuttra — J0225
Aralast NP / Prolastin-C / Zemaira — J0256
Asceniv — J1554
Avsola — Q5121
Benlysta — J0490
Beqvez — J1414
Berinert — J0597
Renflexis — Q5104
Riabni — Q5123
Rituxan — J9312
Rituxan Hycela — J9311
Roctavian — J1412
Rolvedon — J1449
Ruconest — J0596
Ruxience — Q5119
Ryplazim — J2998
Rystiggo — J9333
Sandostatin LAR — J2353
Saphnelo — J0491
Selarsdi — Q9998
Signifor LAR — J2502
Simponi Aria — J1602
Skyrizi — J2327
Sodium hyaluronate (various) — J7320, J7322, J7324, J7325, J7326, J7327, J7329, J7332
Soliris — J1299
Somatuline Depot — J1930
Spevigo — J1747
Stelara — J3357 (verify specific administration codes when submitting)
White blood cell colony stimulating factors — J1442 (see product-specific mapping), J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120
Xembify — J1558
Xenpozyme — J0218
Xeomin — J0588
Xolair — J2357
Zoladex — J9202

Billing Rule

Injectable medications — code list (unclassified code rules)

For unclassified and temporary codes (J3490, J3590) prior authorization is required only for specific high-cost products. Providers must identify the drug by name when requesting authorization under an unclassified code.

Unclassified codes J3490/J3590: Prior authorization required only when used for Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, and Vabysmo.
Effective Oct. 1, 2024: Prior authorization required for Q5133 and Q5135.

Prior Authorization

Transplants and CAR T-cell therapy — prior authorization channel

For transplants and CAR T-cell therapies (including Carvykti, Kymriah, Yescarta), prior authorization and precertification are required through Optum. Contact Optum at 888-936-7246 for transplant and CAR T-cell therapy authorizations. Some transplant-related requests and unclassified drug codes (J3490/J3590) require submission through Optum Transplant.

Call Optum at 888-936-7246 for transplant and CAR T-cell therapy prior authorization.
For certain products billed under J3490/J3590 (for example Aucatzyl, Hemgenix, Amtagvi, Lenmeldy), prior authorization is required through Optum Transplant.
Effective April 1, 2025: Prior authorization required for Aucatzyl (and other specified products) through the Optum Transplant process.

Prior Authorization

Advanced outpatient imaging — notification/authorization

Advanced outpatient imaging (selected CT, MRI, MRA, PET) requires prior notification — providers ordering these procedures are responsible for providing notification prior to scheduling.

Certain CT, MRI, MRA and PET scans: Notification prior to scheduling is required. Use Provider Portal notification tool.

Prior Authorization

Therapy services — prior authorization

Therapy services including occupational, physical, and speech therapy may require prior authorization depending on the service and code. Check the Provider Portal for specific therapy code prior authorization requirements.

Occupational/physical therapy: Examples of CPT/HCPCS that may require authorization include 97012, 97016, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140.
Speech therapy: Examples include 92507, 92508, 92526.

Prior Authorization

VAD and wound vac — prior authorization process

Ventricular assist devices (VAD) and negative-pressure wound therapy (wound vac) require prior authorization. For VADs and wound vacs follow the phone/fax process listed by UnitedHealthcare or call the number on the member's ID card; Optum VAD Case Management may be involved for VADs.

VADs: Prior authorization required. Example CPT codes: 33927, 33928, 33929; HCPCS: Q0507.
Wound vac: Prior authorization required. Example HCPCS: E2402.
For VADs: please call the number on the member's ID card and fax the required form to the Optum VAD Case Management team at 855-282-8929.

Prosthetics noteProsthetics are not DME per the policy guidance.

Injectable medications

DefinitionInjectable medications: drugs capable of being injected intravenously (IV infusion), subcutaneously or intramuscularly; prior authorization is required for listed injectable medications.

Examples (codes)J3262 (Actemra), J0801 (Acthar), J0172 (Aduhelm), J0225 (Amvuttra), Q5121 (Avsola)

Policy scopeMultiple J- and Q- codes for biologics and specialty injectables are included in the prior authorization list.

Unclassified/temporary HCPCS codes

DefinitionUnclassified/temporary HCPCS codes J3490 and J3590 require prior authorization only for specified drugs named in the policy (examples: Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, Vabysmo).

Effective datesOct. 1, 2024 effective for Q5133/Q5135; April 1, 2025 effective for additional J3490/J3590 items as listed in the Transplants section.

Transplant channelCertain J3490/J3590 items (e.g., Aucatzyl, Hemgenix, Amtagvi, Lenmeldy) require prior authorization through Optum Transplant.

Optum (transplant prior authorization)

ResponsibilityTransplant and CAR T-cell therapy services (including named products) require prior authorization via Optum; contact Optum at 888-936-7246.

ScopeIncludes transplant-related services and specific CAR T products (e.g., Carvykti, Kymriah, Yescarta) as noted in the Transplants section.

Unclassified code routingSome unclassified/temporary code items (J3490/J3590) also require Optum Transplant prior authorization per policy instructions.