CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Minnesota Medicaid

Lists services and codes that require prior authorization for UnitedHealthcare Community Plan of Minnesota participating providers (including Senior Care Options, Senior Care Plus, Special Needs Basic Care, and Long Term Services and Support). Describes how to submit prior authorization requests and exceptions for emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Minnesota Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-440-9946.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-04-01policy effective date

Online & phonesubmission methods

Prior authrequirement noted

20+codes listed (excerpt)

800-310-6826OptumRx notification

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 and Codes Requiring Prior Authorization

Prior authorization coverage criteria (partial)

The following service categories and example codes require prior authorization when billed for Minnesota Medicaid members under UnitedHealthcare Community Plan of Minnesota:

Bariatric surgery (Centers of Excellence requirement in some situations) — example CPT codes: 43644, 43775, 43645, 43842, 43659, 43845.

Behavioral health services — prior authorization required; for specific codes and referrals, call the number on the member's health plan ID card.

Bone growth stimulators — prior authorization required; example codes: 20975, 20979, E0760.

BRCA and related breast cancer genetic testing — prior authorization required; example CPT codes: 81432, 81163, 81433, 81164, 81212.

Breast reconstruction (including non-mastectomy reconstruction) — prior authorization required; example CPT codes: 19316, 19318, 19325, 19328, and multiple non-mastectomy reconstruction codes.

Cancer supportive care — outpatient administration of colony-stimulating factor drugs and certain bone‑modifying agents requires prior authorization; example J/Q codes include J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122.

Chemotherapy injectable drugs administered in an outpatient setting for a cancer diagnosis — prior authorization required; includes J9000–J9999 and specified J‑codes (e.g., J0640, J0641, J0642, J1950).

Cardiology and selected cardiovascular procedures — prior authorization required; example CPT/HCPCS codes include 37220, 37226, 37230, 37221, 37227, 37231 (refer to Minnesota Cardiology Prior Authorization and Notification Program for full list).

Cochlear and other auditory implants — prior authorization required; example codes: 69710, 69714, 69930, L8614 (and related auditory implant codes).

Cosmetic and reconstructive procedures — numerous CPT codes listed require prior authorization; some codes may be exempt from prior authorization when billed with certain skin cancer diagnoses (see full policy lists).

Prior authorization coverage indicators (partial)

Services and codes in this section are subject to prior authorization; some entries are additionally designated as experimental/investigational or flagged with special notes:

Prior authorization required: DME, enteral services, genetic/molecular testing, gender dysphoria procedures, femoroacetabular impingement (FAI) procedures, and other services shown in code lists require prior authorization per the policy.

Designation

Experimental/Investigational — selected codes are flagged as experimental/investigational and require prior authorization under that designation (see listed codes).
Special designation/note — some items have additional requirements or notes (e.g., Centers of Excellence, outpatient administration limitations).

This module contains partial code lists; refer to the full policy for comprehensive lists and criteria.

Prior authorization/notification requirements (enumerated codes)

Items listed below require prior authorization or prior notification as indicated (enumerated codes appear in the full lists):

Gender dysphoria treatment — prior authorization required; example CPT codes include 14000, 14001, 14040, 14302, 15734, 15738, 15750, 15757, 15758, 19303, 53410, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 55970, 55980, 56625, 56800, 56805, 57110, 57335, 58661, 58720, 58940, 64856, 64892, 64896.

Genetic and molecular testing — prior authorization required; example CPT codes include 81228, 81229, 81277, 81400, 81401 (and numerous additional molecular/U-codes listed).

Injectable medications — extensive list of J-/Q-codes require prior authorization; some injectable products also require prior notification via OptumRx (see injectable medications section).

General prior authorization and notification instructions

Coverage actions, exceptions, and routing instructions for prior authorization and prior notification:

For certain unclassified and temporary HCPCS/J-codes (examples: C9077, C9090, C9149, C9151, C9157, C9160, C9162, C9166, C9167, C9168, J3490, J3590), prior authorization is required only when used for specified drugs (e.g., Adzynma, Amondys 45, Cosentyx IV, Evkeeza, Nulibry, Omvoh, Revcovi, Vabysmo).

Obtain prior notification for Cimzia, Synagis and Xolair through OptumRx notification services at 800-310-6826 (prior notification to OptumRx may be separate from UnitedHealthcare PA).

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or call 888-397-8129 for assistance.

Prior authorization-required services (partial list)

The following service categories and example codes are identified as requiring prior authorization or notification:

Joint replacement and major musculoskeletal surgeries — prior authorization required; example codes include total hip and knee replacement codes (e.g., 27130, 27132, 27134) and other joint procedure codes listed in policy.

Non-emergent air ambulance transport — prior authorization required; example HCPCS codes: A0430, A0431, A0435, A0436.

Orthognathic and other complex orthopedic/craniofacial procedures — prior authorization required; example codes include the 21xxx series (21245, 21246, etc.).

Orthotics and prosthetics — prior authorization required for specific L‑codes (e.g., L0112, L0170, L0456, L0462).

Obtain authorization via the portal or by phone (888-397-8129) as described in the submission instructions.

Prior authorization requirements (enumerated)

The following procedure groups and example CPT/HCPCS codes require prior authorization or notification as noted:

Pain management: Prior authorization required — example codes: 62350, 62351, 62360, 62361, 62362.

Prostate procedures: Prior authorization required — example codes: 37243, 52441, 52442, 53850, 53852, 55873, 55874.

Radiation therapy / advanced outpatient imaging: Prior authorization or notification required; providers ordering advanced outpatient imaging must provide notification prior to scheduling; example radiation therapy codes: 77520, 77522, 77523, 77525. Submit via portal or call 866-889-8054 for radiology program details.

Rhinoplasty: Prior authorization required — example CPT codes: 30400, 30410, 30420, 30435, 30450, 30460, 30462, 30465.

CPT / HCPCS / Other Codes

Bariatric surgery codes (partial)CPTCovered

43644	Bariatric surgery
43775	Bariatric surgery
43645	Bariatric surgery
43842	Bariatric surgery
43659	Bariatric surgery
43845	Bariatric surgery

Genetic testing & breast reconstruction (partial)mixedCovered

81432	BRCA genetic testing
81163	BRCA genetic testing
81433	BRCA genetic testing
81164	BRCA genetic testing
81212	BRCA genetic testing
19316	Breast reconstruction
19318	Breast reconstruction
19325	Breast reconstruction
19328	Breast reconstruction

Injectable colony-stimulating factor drugsHCPCSCovered

J2506	Pegfilgrastim (Neulasta) - colony-stimulating factor
Q5101	Filgrastim biosimilar (Zarxio) - colony-stimulating factor
Q5110	Filgrastim-aafi (Nivestym) - colony-stimulating factor
Q5122	Pegfilgrastim-apgf (Nyvepra) - biosimilar
Q5111	Pegfilgrastim-cbqv (UDENYCA) - colony-stimulating factor
Q5108	Pegfilgrastim-jmdb (Fulphila) - colony-stimulating factor
Q5120	Pegfilgrastim-bmez (Ziextenzo) - colony-stimulating factor
J1442	Filgrastim (Neupogen)
J1447	Filgrastim-ayow (Releuko)

Chemotherapy injectable drugs requiring prior authorizationHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs (range of J-codes)
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Lupron Depot

Cochlear implantsmixedCovered

69710	Cochlear implant procedure
69714	Cochlear implant
69930	Cochlear implant
L8614	Cochlear implant device HCPCS

Sample DME HCPCS codes (partial)HCPCSCovered

A9279	DME - unspecified
A9280	DME - unspecified
E0194	DME item
E0265	DME item
E0266	DME item
E0270	DME item

FAI procedure CPT codes (partial)CPTCovered

29914	Arthroscopy procedures (FAI)
29915	Arthroscopy procedures (FAI)
29916	Arthroscopy procedures (FAI)

Genetic/molecular test codes (partial)CPTCovered

81228	Genetic testing
81229	Genetic testing
81400	Molecular pathology

Selected procedure codes (gender dysphoria and related procedures)CPTCovered

14000	Excision of lesion; primary closure
14001	Excision of lesion; secondary closure
14040	Skin flap
14302	Skin graft

Genetic and molecular testing codesmixedCovered

81228	CYP2C19
81479	Unlisted molecular pathology procedure
0250U	Proprietary molecular test (example U-code)

Home health codesHCPCSCovered

G0299

Home health - prior authorization required

Injectable medication J-/Q-codesHCPCSCovered

J3262	Injectable medication (example listed)
J0177	Aflibercept
J9312	Rituximab

Unclassified/temporary HCPCS/J-codes referencedHCPCS

C9077	Unclassified/temporary HCPCS code (example list)
C9090	Unclassified/temporary HCPCS code (example list)
C9149	Unclassified/temporary HCPCS code (example list)
C9151	Unclassified/temporary HCPCS code (example list)
C9157	Unclassified/temporary HCPCS code (example list)
C9160	Unclassified/temporary HCPCS code (example list)
C9162	Unclassified/temporary HCPCS code (example list)
C9166	Unclassified/temporary HCPCS code (example list)
C9167	Unclassified/temporary HCPCS code (example list)
C9168	Unclassified/temporary HCPCS code (example list)

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CPT/HCPCS authorization entries (mostly blank)CPT | HCPCS

No codes listed

Code types referencedmixed

CPT/HCPCS

Indicates CPT or HCPCS codes are referenced for prior authorization requests

CPT/HCPCS guidancemixed

No codes listed

Priority codes listed in this sectionmixedCovered

27130	Total hip replacement (example code present in list)
27447	Knee arthroplasty (example code present in list)
A0430	Non-emergent air ambulance transport
L0112	Orthotic/prosthetic supply code

Selected CPT/HCPCS codes requiring prior authorizationmixedCovered

62350	Epidural injection; cervical or thoracic, single level
62360	Injection(s), diagnostic or therapeutic agent, epidural or subarachnoid, lumbar
0098T	Stimulator implantation (example listed)
E0749	Bone growth stimulator
77520	Radiation treatment delivery

Outpatient administration requirement

RequirementCancer supportive care (colony-stimulating factors) and chemotherapy injectable drugs require prior authorization when administered in an outpatient setting for a cancer diagnosis.

Examples (codes)J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125 (colony-stimulating factor agents)

ScopeApplies to outpatient administration only for cancer diagnosis; see Injectable medications section for non-oncology DX requirements.

How to Request Prior Authorization and Notifications

Prior Authorization

How to request prior authorization

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or by phone at 877-440-9946. Prior authorization is not required for emergency or urgent care; out-of-network providers must request authorization for non-emergent services.

Prior Authorization

Cardiology prior authorization contact

Cardiology prior authorization requests may be submitted online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by calling 866-889-8054; refer to Minnesota's Cardiology Prior Authorization and Notification Program for the CPT codes that require prior authorization.

Prior Authorization

DME prior authorization (partial list)

Durable medical equipment (DME) HCPCS codes shown (examples include A9279, A9280, E0194, E0265, E0266, E0270, etc.) require prior authorization; some items have notes about retail purchase or cumulative rental cost thresholds.

Key Terms and Exceptions

Prior authorization definition / request approval before rendering

DefinitionPrior authorization: Request approval before rendering a service as required by UnitedHealthcare policy; advance notification gives UnitedHealthcare timely communication.

PurposeRequired for specified services, codes, and medications to determine coverage before care is provided.

Submission channelsSubmit via Prior Authorization and Notification tool on UHCprovider.com or by phone (877-440-9946).

Emergency/urgent care exception

ExceptionEmergency or urgent care services do not require prior authorization.

Out-of-network noteOut-of-network providers must request authorization for non-emergent services (emergent/urgent care excluded).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Minnesota Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-440-9946.

SourceLink

On This Page

Shoulder surgery: Prior authorization required — example CPT codes: 29805, 29806, 29807, 29819, 29820, 29822, 29823, 29824, 29825, 29826, 29827, 29828.

Sinuplasty and sleep apnea surgery: Prior authorization required — example sinuplasty codes: 31295, 31296, 31297, 31298; sleep apnea-related codes include 21685, 41599, 42145.

Spinal surgery and neurosurgery implants: Prior authorization required — example codes include multiple spine CPTs (e.g., 20930, 20931, 20939, 22100, 22510, 22600, 22800, 63001, 63101, 63200, 63300) and extensive related codes listed in policy.

Stimulators and implantation devices: Prior authorization required — example codes: 0098T, E0749, 61863, 63650, 64553, 0312T, L8680, L8682 (bone growth stimulators and implanted neurostimulator device codes included).

Transplants and CAR-T: Prior authorization required — transplant and CAR-T‑cell therapy services require prior authorization (header indicates requirement; details provided in transplant section).

Example DME codes listed: A9279, A9280, E0194, E0265, E0266, E0270

Prior Authorization

Enteral services prior authorization

Enteral services require prior authorization for listed enteral HCPCS codes (examples: B9002, B9998).

Enteral HCPCS codes: B9002, B9998

Prior Authorization

Procedural prior authorization (FAI, endoscopic sinus, functional)

Procedures for femoroacetabular impingement (FAI) and various endoscopic sinus/functional procedures require prior authorization; example CPT codes include 29914–29916 (FAI) and multiple 312xx codes for endoscopic/functional sinus procedures.

FAI CPT codes: 29914, 29915, 29916
Endoscopic/functional sinus CPT codes: 31240, 31253–31259, 31267, 31276, 31287, 31288

Prior Authorization

Gender dysphoria treatment prior authorization

Multiple procedure codes associated with gender dysphoria treatment are marked as requiring prior authorization; examples include CPT codes 14000, 14001, 14040, 14302, and numerous reconstructive procedure codes listed in the policy.

Example gender dysphoria CPT codes: 14000, 14001, 14040, 14302, 15734, 19303

Prior Authorization

Experimental/investigational prior authorization

Selected services are designated as experimental and investigational and require prior authorization under that designation; example codes flagged include 33477, 36514 and 64722.

Example experimental/investigational CPT codes: 33477, 36514, 64722

Prior Authorization

Genetic/molecular testing prior authorization

Genetic and molecular testing codes require prior authorization; examples include 81228, 81229, 81277, 81400–81403 and numerous additional molecular/U-codes listed in the policy.

Example genetic/molecular CPT codes: 81228, 81229, 81277, 81400, 81401, 81402, 81403

Prior Authorization

Prior authorization submission instructions

For prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or call 888-397-8129.

Documentation Required

OptumRx prior notification

Obtain prior notification for Cimzia, Synagis and Xolair through OptumRx notification services at 800-310-6826.

OptumRx notifications phone: 800-310-6826

Prior Authorization

Procedure codes requiring prior authorization

The policy lists numerous surgical and procedure CPT codes that require prior authorization (including gender dysphoria–related codes and other procedures); refer to the enumerated code lists in the policy when submitting requests.

Prior Authorization

Genetic and molecular testing prior authorization

Genetic and molecular testing and many proprietary/U-codes require prior authorization/notification before testing; ordering providers must follow the authorization/notification process outlined for laboratory testing.

Ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare for certain tests (per policy).

Prior Authorization

Home health prior authorization

Home health care requires prior authorization for the listed G- and S-codes (examples include G0299, G0495, G0300, G0496, G0493, S9474, G0494).

Home health codes: G0299, G0495, G0300, G0496, G0493, S9474, G0494

Prior Authorization

Hysterectomy prior authorization

Hysterectomy CPT codes require prior authorization; example codes listed include 58150, 58152, 58180, 58260, 58263 and others shown in the policy.

Example hysterectomy CPT codes: 58150, 58152, 58180, 58260, 58263

Prior Authorization

Injectable medications prior authorization

Extensive lists of injectable medications (J-, Q- and other HCPCS/J-codes) require prior authorization; some agents may instead require prior notification via OptumRx per the policy.

Policy includes long enumerated lists of injectable medication J-/Q-codes requiring prior authorization
Some unclassified/temporary codes require PA only for specific drugs (see policy)

Prior Authorization

Unclassified/temporary codes authorization exceptions

For certain unclassified and temporary HCPCS/J-codes (examples: C9090, C9149, C9151, C9160, C9162, C9166, C9167, C9168, J3490, J3590, C9077), prior authorization is required only when used for specified drugs (Adzynma, Amondys 45, Cosentyx IV, Evkeeza, Nulibry, Omvoh, Revcovi, Vabysmo).

Unclassified/temporary codes with drug-specific PA: C9077, C9090, C9149, C9151, C9157, C9160, C9162, C9166, C9167, C9168, J3490, J3590
Specified drugs listed: Adzynma, Amondys 45, Cosentyx IV, Evkeeza, Nulibry, Omvoh, Revcovi, Vabysmo

Prior Authorization

How to obtain prior authorization or notification

Prior authorization or prior notification is obtained by submitting requests through the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or by calling the phone contacts provided for the specific program or service.

Portal: UHCprovider.com → Sign In → Prior Authorization and Notification
Phone contacts vary by program (see specific sections)

Documentation Required

OptumRx prior notification

Obtain prior notification for Cimzia, Synagis and Xolair via OptumRx notification services at 800-310-6826 (OptumRx handles prior notification for these biologics).

OptumRx notifications phone: 800-310-6826

Note

General prior authorization contact

For general prior authorization inquiries and submission, use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129 as noted in the policy.

General PA phone contact referenced: 888-397-8129
Portal submission: UHCprovider.com Prior Authorization and Notification tool

Prior Authorization

How to submit prior authorization

For prior authorization, please submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (Go to UHCprovider.com → Sign In → Prior Authorization and Notification) or call 888-397-8129.

Prior Authorization

Portal and phone contact

Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool to submit authorizations, or contact by phone; portal access is via UHCprovider.com → Sign In → Prior Authorization and Notification. Phone contact cited in the policy is 888-397-8129.

Portal navigation: UHCprovider.com → Sign In → Prior Authorization and Notification
Phone: 888-397-8129

Prior Authorization

Submission methods

Submission methods accepted are online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling 888-397-8129.

Prior Authorization

How to obtain prior authorization

Use the Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or call 888-397-8129 to obtain prior authorization/notification.

Prior Authorization

Services and codes requiring prior authorization

Specific CPT/HCPCS codes and service categories require prior authorization as listed throughout the policy (examples across sections include joint replacement, musculoskeletal and orthotic/prosthetic codes). Refer to the policy code lists when preparing PA requests.

Examples: total hip/knee replacement codes, non-emergent air ambulance codes, orthotics/prosthetics codes

Prior Authorization

Pain management and device codes prior authorization

Prior authorization is required for listed L-codes and specified pain management CPT codes (examples include L7405, L8040–L8047 and CPT codes 62350–62362).

Example L-codes: L7405, L8040, L8042–L8047
Pain management CPT examples: 62350, 62351, 62360, 62361, 62362

Prior Authorization

Prostate procedures prior authorization

Prior authorization is required for listed prostate procedure CPT codes such as 37243, 52441, 52442, 53850, 53852, 55873 and 55874.

Example prostate CPT codes: 37243, 52441, 52442, 53850, 53852, 55873, 55874

Prior Authorization

Radiology and radiation therapy prior authorization/notification

Prior authorization is required for certain radiation therapy and advanced outpatient imaging procedures; providers ordering advanced outpatient imaging must provide notification prior to scheduling and may use the Prior Authorization and Notification tool or call 866-889-8054.

Example radiation therapy codes: 77520, 77522, 77523, 77525
Radiology contact/notification phone: 866-889-8054

Prior Authorization

Rhinoplasty prior authorization

Rhinoplasty procedures require prior authorization for the listed CPT codes (examples include 30400, 30410, 30420, 30435, 30450, 30460, 30462, 30465).

Example rhinoplasty CPT codes: 30400, 30410, 30420, 30435, 30450, 30460, 30462, 30465

Prior Authorization

Shoulder surgery prior authorization

Shoulder surgery procedures (arthroscopic and shoulder CPT codes) require prior authorization; example codes listed include 29805, 29806, 29807, 29819–29828.

Example shoulder CPT codes: 29805, 29806, 29807, 29819, 29820, 29822–29828

Prior Authorization

ENT and sleep apnea surgery prior authorization

Sinuplasty and certain sleep apnea surgical procedures (including maxillomandibular advancement) require prior authorization; example CPT codes include 31295–31298 and 21685.

Sinuplasty codes: 31295, 31296, 31297, 31298
Sleep apnea example: 21685

Prior Authorization

Spinal, neurosurgery, and stimulator implantation prior authorization

Spinal surgery, various neurosurgery/implantation and stimulator implantation CPT/HCPCS codes require prior authorization; examples include numerous spinal CPT codes (20930–228xx, 63001–631xx) and device/stimulator codes (0098T, E0749, L8680–L8688).

Example spinal/neurosurgery CPTs: 20930, 22100, 22510, 22600, 22800, 63001, 63101
Stimulator/device examples: 0098T, E0749, L8680, L8682–L8688

Prior Authorization

Transplants and CAR-T prior authorization

Transplant and CAR‑T‑cell therapy services require prior authorization (policy header indicates requirement; details and codes are provided elsewhere in the policy).

Prior Authorization

How to obtain prior authorization/notification

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or call 866-889-8054 to submit prior authorization/notification for advanced outpatient imaging and related services per the Radiology Prior Authorization and Notification Program.

Portal: UHCprovider.com → Sign In → Prior Authorization and Notification
Radiology phone contact: 866-889-8054

RationaleAdvance notification is not required when services are emergent or urgent to avoid delays in care.

Durable medical equipment (DME)

DefinitionDurable medical equipment (DME): items of DME listed in the policy require prior authorization.

Sample codesA9279, A9280, E0194, E0265, E0266, E0270 (partial list)

NotesSome items reference retail purchase or cumulative rental cost thresholds for authorization determination.

Enteral services

DefinitionEnteral services: enteral HCPCS codes listed in the policy require prior authorization.

Sample codesB9002, B9998 (partial list)

InstructionObtain prior authorization for enteral supplies prior to provision as listed in policy codes.

Gender dysphoria treatment

DefinitionGender dysphoria treatment: multiple surgical and procedural CPT codes related to gender-affirming care require prior authorization.

Examples (codes)14000, 14001, 14040, 14302, 15734, 15738, 15750, 15757, 15758, 19303, 53410, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 55970, 55980 (partial list)

RequirementAuthorization must be obtained before scheduling or performing procedures listed under gender dysphoria treatment.

Prior notification via OptumRx

DefinitionPrior notification via OptumRx: notification to OptumRx is required for certain biologic agents (e.g., Cimzia, Synagis, Xolair).

OptumRx phone800-310-6826 (OptumRx notifications services)

When to useUse OptumRx notification process for designated biologics separate from UnitedHealthcare PA where indicated.

Prior authorization submission

Submission methodsSubmit prior authorization requests online using the Prior Authorization and Notification tool on UHCprovider.com or by phone (888-397-8129 or 877-440-9946 as listed in sections).

Portal pathUHCprovider.com → Sign In → Prior Authorization and Notification on the Provider Portal dashboard.

Alternate phoneCall 888-397-8129 or 877-440-9946 for assistance or to submit by phone per document sections.

prior authorization (definition)

Definition (PA)Prior authorization (PA): the payer review and approval process required before certain services, codes, or medications will be covered.

PurposeEnsures UnitedHealthcare review and determination of coverage prior to rendering specified services.

Provider actionObtain approval via the online Prior Authorization and Notification tool or by phone as specified in policy sections.

prior notification (definition)

Definition (prior notification)Prior notification: notification to the pharmacy benefit manager (OptumRx) for certain biologic agents (e.g., Cimzia, Synagis, Xolair); may be separate from UnitedHealthcare PA.

OptumRx contact800-310-6826 for prior notification of designated biologics.

DistinctionPrior notification via OptumRx is distinct from PA and required for specific drugs listed in the policy.

OptumRx prior authorization contact

OptumRx phone888-397-8129 is shown repeatedly as a contact associated with OptumRx/authorization references in the document.

Alternate OptumRx contactOptumRx notifications services also listed at 800-310-6826 for specific biologics.

UseContact OptumRx for prior authorization/notification assistance as indicated by the policy sections referencing OptumRx.

Prior Authorization and Notification tool

Tool namePrior Authorization and Notification tool: the online submission tool on the UnitedHealthcare Provider Portal used to submit prior authorization requests.

Access instructionsGo to UHCprovider.com → Sign In → select Prior Authorization and Notification on your Provider Portal dashboard.

Alternate submissionIf unable to use the tool, call the phone numbers listed in the policy sections for assistance.

Prior Authorization and Notification tool (dashboard)

Dashboard featureThe Prior Authorization and Notification tool appears on the UHCprovider.com dashboard for providers to submit and track PA requests.

NavigationSign in to the Provider Portal and select Prior Authorization and Notification on your dashboard to open the tool.

SupportUse portal help or phone contact if access or submission problems occur.

Authorization portal

Portal nameAuthorization portal: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

How to reachUHCprovider.com → Sign In → Prior Authorization and Notification on dashboard; call 888-397-8129 if needed.

PurposePrimary method for submitting prior authorization and notification requests described in the policy.

Non-emergent air ambulance transport

DefinitionNon-emergent air ambulance transport: non-emergent air ambulance transport codes A0430, A0431, A0435, A0436 require prior authorization.

Sample codesA0430, A0431, A0435, A0436

ActionObtain prior authorization prior to arranging non-emergent air ambulance transport.

Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)

DefinitionPrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com): primary online method to submit PA/notification.

Access stepsGo to UHCprovider.com → Sign In → select Prior Authorization and Notification on your dashboard.

Phone alternativeIf needed, call 888-397-8129 or the phone listed for the specific program (e.g., 866-889-8054 for radiology).