CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for District of Columbia LTSS

Lists services and codes that require prior authorization for participating UnitedHealthcare Community Plan (District of Columbia) Long-Term Services and Supports (LTSS) providers and explains how to submit requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for District of Columbia LTSS

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 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 888-702-2202.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservice types listed requiring prior authorization

888-702-2202phone option

Provider Portalonline submission

2025-10-01policy effective

Services Requiring Prior Authorization

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ALL of the following

CPT/HCPCS codes: 97813, 97814

ALL of the following

CPT code: 43842

ALL of the following

Definition: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational speech.
HCPCS code: L8692

ALL of the following

For items with retail purchase or cumulative rental cost less than $500
- Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of less than $500.
- Example DME codes: E0221, E1130, E1290, E0638, E1140, E1086, E1250, E1090, E1260
For items with retail purchase or cumulative rental cost greater than $500
- Prior authorization required only for the code(s) listed with a retail purchase or a cumulative rental cost of more than $500.
- Example DME codes: E0194, E0483, E0304, E0636, E0465, E0692, E0466, E0693, E2510, K0806, K0837, K0841, K0850, K0855, K0108, K0808, K0838, K0843, K0851, K0856, K0860, K0800, K0835, K0839, K0848, K0852, K0801, K0836, K0840, K0849, K0854, K0858

ALL of the following

HCPCS codes: B4102, B4103, B4104

ALL of the following

Example CPT codes: 65765, 65767

ALL of the following

No specific codes listed in source.

ALL of the following

Example HCPCS code: T1502

ALL of the following

HCPCS codes: A0430, A0431, A0435, A0436

ALL of the following

HCPCS codes: T1001, T1002, T1003, T1004

ALL of the following

Applies to certain CT, MRI, MRA, PET scans and nuclear medicine/nuclear cardiology procedures; providers must notify/schedule via the Prior Authorization and Notification tool.

Codes and Coding Rules

Examples of listed CPT/HCPCS codes requiring prior authorizationCPT | HCPCSCovered

97813	Acupuncture CPT/HCPCS code
97814	Acupuncture CPT/HCPCS code
43842	Bariatric surgery code listed
L8692	Cochlear implant HCPCS code

Additional listed HCPCS/T codesHCPCS | CPTCovered

B4102	Enteral services/home nutritional therapy
B4103	Enteral services/home nutritional therapy
B4104	Enteral services/home nutritional therapy
T1502	Home health care
A0430	Non emergency transportation
A0431	Non emergency transportation
A0435	Non emergency transportation
A0436	Non emergency transportation
T1004	Private duty nursing (PDN)
T1001	Private duty nursing (PDN)

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DME prior authorization threshold

Threshold for DME prior authorizationPrior authorization required only for DME codes with a retail purchase or cumulative rental cost greater than $500 (or when specifically listed).

DME items with retail/cumulative cost <= $500Some DME codes are only subject to prior authorization when retail purchase or cumulative rental cost is greater than $500; lower‑cost items may be exempt unless otherwise listed.

Codes listed that may trigger PA under threshold rulesExamples of DME codes included in lists: E0221, E1130, E1290, E0638, E1140, E1086, E1250 (see code lists).

Greater-than-$500 DME code examplesExamples of DME codes specifically noted as >$500 and requiring prior authorization: E0194, E0483, E0304, E0636, E0465, E0692, E0466, E0693.

How to Submit and Notification Requirements

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 888-702-2202.

Online: Go to UHCprovider.com, sign in with your One Healthcare ID, then select the Prior Authorization and Notification tab on your dashboard.
Phone: Call 888-702-2202.

Prior Authorization

Advanced outpatient imaging — portal notification required

Providers ordering advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures) are responsible for providing notification and scheduling the procedure via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Use the Prior Authorization and Notification tool on UHCprovider.com and select the Prior Authorization and Notification tab to provide notification and schedule the procedure.

Prior Authorization

DME prior authorization codes and cost thresholds

Durable medical equipment (DME) items listed require prior authorization; prior authorization is required for codes with a retail purchase or cumulative rental cost greater than $500 (or when specifically listed).

Prior authorization required for listed DME codes with retail purchase or cumulative rental cost more than $500.
Specific DME HCPCS codes that require prior authorization are listed in the policy (e.g., E0221, E1130, E1290, E2510, K0806, K0837, etc.).

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for District of Columbia LTSS

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 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 888-702-2202.

SourceLink

On This Page

OpenPayer

Prior Authorization Requirements for District of Columbia LTSS

Services Requiring Prior Authorization

Codes and Coding Rules

How to Submit and Notification Requirements

Key Definitions

Policy Revision History