How to submit prior authorization requests and general rules

Submit prior authorization and notification requests using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool. Sign in at UHCprovider.com with One Healthcare ID; if you do not have one, visit UHCprovider.com/access. When requesting authorizations reference the member-specific benefit plan document — benefits and rules vary by state. Prior authorization is not required for emergency or urgent care. Site-of-service review may apply to listed codes.

• Online: UHCprovider.com → Prior Authorization and Notification tab
• If questions or prior authorization support for injectable/specialty agents, call Optum Specialty Guidance Program 888-397-8129

Body lengthening and device prior authorization

Prior authorization is required for body lengthening procedures and related devices. Site-of-service review may apply for all states except Texas and Wisconsin (those states require PA for listed codes but are excluded from site-of-service review).

• Affected CPT/HCPCS codes include: 27685, 20975, 20979, and HCPCS E0747
• Ensure prior authorization is obtained before scheduling services

Chemotherapy prior authorization (partial list)

Prior authorization is required for chemotherapy agents and many related supportive drugs and services. For outpatient oncology supportive agents and many chemotherapy drugs, submit requests online via the Provider Portal. Some agents require predetermination.

• Selected chemotherapy/oncology J-codes listed in policy (partial): J0640, J1950, J9015, J9021, J9027, J9033, J9037, J9042, J9047, J9051, J9057, J9061, J9070, J9074, J9118, J9130, J9144–J9181 (cont.), and many others
• Prior authorization required for inpatient chemo services in some cases; outpatient hospital/ASC may be excluded — check member plan
• Colony-stimulating factors and bone-modifying agents administered outpatient for cancer diagnoses require prior authorization (examples: J1442, J1447, J2506, J2820, Q51xx)

Prior authorization for chemotherapy and clinical trials

Prior authorization and special handling apply when chemotherapy or investigational treatments are provided within clinical trials or human-subjects research that is IRB‑oversighted. Submit requests via the Provider Portal and include trial documentation.

• Human subjects/IRB‑oversight: prior authorization may be required — include protocol and IRB documentation when submitting
• Contact Optum Specialty Guidance Program for specialty agent routing and questions

Community Support — Illinois

Community support services have a prior authorization requirement for Illinois Individual Exchange plans.

• Applies to Illinois only
• Affected HCPCS/CPT codes include H0037, H0040, T1024

Congenital heart disease prior authorization

Congenital heart disease–related services (including pretreatment) require prior authorization. Site-of-service and age-based rules may apply.

• Selected codes include: 33202, 33251, 33254, 33897, 33917, 33920, 33924, 33925–33926, and advanced cath/EP codes 93580–93598 where indicated
• Some codes require PA for members age 18 and older — see cardiovascular section for age-specific notes

Continuous glucose monitoring prior authorization

Continuous glucose monitoring (CGM) prior authorization rules vary by indication. Prior authorization is not required for members with type 1 diabetes; authorization may be required for other indications.

• Devices/HCPCS examples: A4226, A4238
• Prior authorization required for non–type 1 diabetes indications; verify member plan and documentation

Foot surgery prior authorization

Foot surgery procedures listed require prior authorization. Site-of-service review may apply for all states except Texas and Wisconsin (those states require PA for listed codes but are excluded from site-of-service review).

• Selected CPT codes: 28285, 28289, 28291–28299, 28295–28299 (partial list)
• Obtain prior authorization before elective foot surgery and verify site-of-service requirements

K‑code prior authorization and state exclusions

K‑code (DME) prior authorization is required for many items; state-specific exclusions apply. Verify exclusions by state before submitting requests.

• Examples: K0835–K0864, K0890–K0900 and S1040 (many codes have state exclusions)
• Notes: *New Mexico, South Carolina and Wisconsin are excluded for some codes; other codes exclude Iowa, Nebraska, Wyoming, Indiana — review code footnotes in policy

Provider notification to laboratory

Providers must notify the performing laboratory for certain genetic/molecular tests before testing. The lab will then notify UnitedHealthcare as required by the Genetic and Molecular Testing Prior Authorization/Notification Program.

• Provider must notify laboratory for listed U‑codes (examples include 0506U, 0508U, 0523U, 0530U, 0536U, 0538U)
• The laboratory may be responsible for notifying UnitedHealthcare for some tests; follow the policy instructions and program registration

Unclassified injectable codes exceptions

Unclassified injectable HCPCS codes (J3490, J3590) require notification/prior authorization only for specific agents. Predetermination or PA is required for those named agents.

• Notification/PA required for J3490/J3590 when billing for Nulibry, Revcovi, Rivfloza
• For questions or to submit PA for unclassified injectables, use the Provider Portal or call Optum Specialty Guidance Program 888-397-8129

Prior authorization / Predetermination for injectable medications (partial)

Injectable medications frequently require prior authorization or predetermination. Submit requests online via the Provider Portal and include clinical documentation. Some J‑codes are listed as predetermination — verify requirements for each agent.

• Examples of injectable/predetermination codes (partial): J0873–J0884 series, J0887–J0895 series, J2428, J2430, J2440, J2469, J2470–J2472, J2501–J2502, J2510, J2515, J2540, J2543, J2545, J2547, J2550
• For specialty/complex injectables, contact Optum Specialty Guidance Program 888-397-8129

Prior authorization required for listed CPT/HCPCS codes

Prior authorization is required for the CPT/HCPCS codes listed throughout this section. Site‑of‑service review may apply to many of these codes and to specific states; always verify member benefits and state-specific exceptions before rendering services.

• Examples (non‑exhaustive): numerous surgical CPT codes (arthroplasty, arthroscopy, orthognathic, neurostimulator implantation), J‑codes for injectables, L‑ and K‑codes for orthotics/prosthetics and DME, and Q/S codes referenced in this policy
• Site-of-service review exceptions: Texas and Wisconsin frequently excluded from site-of-service review for listed codes; other state exclusions noted by code footnotes

Orthognathic surgery prior authorization

Orthognathic (maxillofacial) surgery requires prior authorization. Many CPT codes are listed; some codes are excluded in specific states (e.g., South Carolina).

• Representative codes: 21010, 21050, 21060, 21121, 21123, 21125, 21127, 21141–21255, 21296 (partial list)
• Verify state exclusions and obtain PA before scheduling services

Prior authorization and site‑of‑service note

For many procedures and services, prior authorization will include a site‑of‑service review; when site‑of‑service review applies the location of service may affect coverage. Texas and Wisconsin are frequently excluded from site‑of‑service review for codes where other states have site‑of‑service requirements — however those two states may still require PA for the codes.

• When site‑of‑service review applies, UnitedHealthcare may deny or redirect services to an alternative setting if medically appropriate
• Always confirm member benefits and any state-specific exceptions (e.g., Texas, Wisconsin, and other code footnotes) prior to scheduling

Support contact for injectable prior authorization (Optum SGP)

For questions about injectable prior authorization and specialty guidance, call the Optum Specialty Guidance Program (SGP) at 888‑397‑8129. This contact is provided to support providers submitting PA for injectable/specialty medications.

• Optum SGP phone: 888‑397‑8129

How to submit prior authorization requests — portal and support resources

Submit prior authorization requests online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com; sign in with One Healthcare ID). For injectable/specialty questions, call Optum SGP at 888‑397‑8129. Prior authorization is not required for emergency or urgent care.

• Portal submission: UHCprovider.com → Prior Authorization and Notification tab
• Optum SGP for specialty injectable questions: 888‑397‑8129
• Reference member‑specific benefit plan for coverage determination