CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Mississippi - Mississippi Coordinated Access Network (MississippiCAN)

Lists prior authorization requirements and submission instructions for providers participating with UnitedHealthcare Community Plan in the Mississippi Coordinated Access Network (MississippiCAN). Applies to inpatient and outpatient services and participating (in-network) and out-of-network providers in Mississippi.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Mississippi - Mississippi Coordinated Access Network (MississippiCAN)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateEffective Apr. 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or by phone 877-842-3210 or fax 888-310-6858.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UHCprovider.comProvider Portal

877-842-3210Phone (prior auth)

888-310-6858Fax (prior auth)

No PA requiredEmergency care

5 business days

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24 hoursAdmission notification

Services and Situations Requiring Prior Authorization

Authorization requirements (excerpt)

Authorization requirements (excerpt) — selected procedure categories and authorization stance

ALL of the following

Transplants: Prior authorization required. For transplant and CAR T-cell therapy services (including Abecma, Breyanzi, Kymriah, Tecartus, Yescarta) contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card.
Chemotherapy (injectable): Prior authorization required for outpatient administration (intravenous, intravesical, intrathecal) for cancer diagnoses. Applies to chemotherapy injectable drugs (J9000–J9999), Leucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), Leuprolide (J1952), chemotherapy drugs with Q-codes, and miscellaneous/unassigned HCPCS billed agents.
Radiation therapy and radiation oncology procedures: Prior authorization required. Use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal and select the Radiology, Cardiology, Oncology, and Radiation Therapy box (after selecting Commercial product type you will be directed to the external site to process requests).
Advanced outpatient imaging (Radiology): Prior authorization or prior notification required for advanced outpatient imaging procedures; care providers must provide notification prior to scheduling.
Spinal surgery and major spine procedures: Prior authorization required for listed CPT codes (e.g., 22100–22224, 22510–22554 and others referenced).
Joint replacement (total hip and knee): Prior authorization required for joint replacement procedures (e.g., CPT codes in the 27120–27138 and 27412–27447 ranges listed).
Stimulators and neurostimulator implantation: Prior authorization required for implantation of stimulators and associated device HCPCS (e.g., E0748, E0749, E0760, E0748–E0760, and CPT codes such as 61863–61868, 63650, 63655, 63685, 64553, 64555, 64568, 64570) as noted.
Transcatheter and cardiovascular procedures: Prior authorization required for cardiovascular interventions and listed CPT codes (e.g., 37220–37227 and related codes indicated).
Wound VAC (negative pressure wound therapy): Prior authorization required (e.g., HCPCS E2402).
Durable medical equipment (DME): Prior authorization required only for the specific DME/HCPCS codes listed (examples include A6549, A9280, A9900, B4152, B4161, E0194, E0265, E0266, E0270, E0277, E0300, K0885, K0886, V5281–V5290 as applicable).
Orthotics and prosthetics: Prior authorization required only for the orthotics and prosthetic codes listed (examples: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0637, L0632, L0634, L0636, etc.).
Enteral and parenteral services (in-home nutritional therapy): Prior authorization required for specified enteral/parenteral products and HCPCS codes (e.g., B4034–B4036, B9002). Some products are pharmacy point-of-sale items dispensed via OptumRx — refer to state PDL and pharmacy benefit for coverage/payment.
Hearing aids: Prior authorization required for hearing aid services and associated CPT/HCPCS codes (e.g., 92591, 92595, V5010, V5030, V5050, V5060, V5255, V5256, V5281–V5290 as listed).
Sleep studies and sleep apnea surgeries/procedures: Prior authorization required for sleep studies (e.g., CPT 95805, 95807, 95808, 95810, 95811) and for specified sleep apnea surgeries such as maxillomandibular advancement (e.g., CPT 21685, 41599, 42145).
Elective/planned inpatient admissions: Prior authorization required at least 5 business days prior to non-urgent outpatient services and elective/planned inpatient admissions; emergent/urgent inpatient admissions do not require prior authorization but require notification within 24 hours.
Out-of-network services: All out-of-network services require prior authorization for referral to non-contracted providers.
Cancer supportive care (injectable colony-stimulating factors): Prior authorization required for agents such as Filgrastim and listed Q-codes (e.g., Q5110, Q5125) and other injectable supportive care drugs specified.
Injectable medications: Prior authorization required for many specified injectables (examples listed in policy, including but not limited to Actemra J3262, Acthar J0801, Adakveo J0791, Aduhelm J0172, and others).

Relevant CPT, HCPCS, and ICD-10 Codes

Bone growth stimulator CPT/HCPCS examplesCPTCovered

20975	Bone growth stimulator (listed in document)
20979	Bone growth stimulator (listed in document)

Breast reconstruction CPT/HCPCS codes requiring prior authorizationCPT | HCPCSCovered

11971	Breast reconstruction (non-mastectomy)
19318	Breast reconstruction (non-mastectomy)
19328	Breast reconstruction (non-mastectomy)
19330	Breast reconstruction (non-mastectomy)
19340	Breast reconstruction (non-mastectomy)
19342	Breast reconstruction (non-mastectomy)
19350	Breast reconstruction (non-mastectomy)
19357	Breast reconstruction (non-mastectomy)
19361	Breast reconstruction (non-mastectomy)
19364	Breast reconstruction (non-mastectomy)

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Cancer supportive care (colony-stimulating factors)HCPCSCovered

Q5110	Filgrastim-ayow (Releuko®)
Q5125	Filgrastim-sndz (Zarxio®)

Cardiovascular/cardiology CPT codesCPTCovered

37220	Cardiovascular procedure code listed with prior authorization
37221	Cardiovascular procedure code listed with prior authorization
37224	Cardiovascular procedure code listed with prior authorization
37225	Cardiovascular procedure code listed with prior authorization
37226	Cardiovascular procedure code listed with prior authorization
37227	Cardiovascular procedure code listed with prior authorization
37228	Cardiovascular procedure code listed with prior authorization
37229	Cardiovascular procedure code listed with prior authorization
37230	Cardiovascular procedure code listed with prior authorization
37231	Cardiovascular procedure code listed with prior authorization

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Examples of codes referencedHCPCS | CPT

J9000-J9999	Chemotherapy injectable drugs range (HCPCS J-codes)
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Lupron Depot
J1952	Leuprolide
54161	Circumcision
69714	Cochlear implant related CPT
69930	Cochlear implant related CPT
L8614	Cochlear implant HCPCS

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Procedural CPT/HCPCS codes (partial list)mixed

21282
28344
30620
67900
67901

Diagnosis ICD-10 codes (partial list)ICD-10

C43.0	Malignant melanoma of skin (root examples present across C43 series)
C44.101	Malignant neoplasm of skin - example ICD-10 codes listed

DME/HCPCS codes (partial list)HCPCS

E0328	Equipment where cumulative rental cost more than $500 - outpatient
E0693
E1002
K0854

Selected procedure and genetic testing codesmixed

29914	Femoroacetabular impingement syndrome (FAI) procedure code
29915	Femoroacetabular impingement syndrome (FAI) procedure code
29916	Femoroacetabular impingement syndrome (FAI) procedure code
31256	sinus surgery (FESS) code
31276	sinus surgery (FESS) code
81162	Genetic testing/BRCA-related code
81229	Genetic testing/BRCA-related code

Selected injectable medication J-codesHCPCSCovered

J3262	Actemra
J0801	Acthar
J0567	Brineura
J2329	Briumvi
J1439	Injectafer
J1300	Soliris
J1303	Ultomiris

Sample CPT/HCPCS codes requiring prior authorization (partial list)mixedCovered

J0256	Zoladex
J9202	Zolgensma
J3399	Unspecified drug codes (example listed)
A0430	Non-emergent air ambulance transport
A0431	Non-emergent air ambulance transport
A0435	Non-emergent air ambulance transport
A0436	Non-emergent air ambulance transport
23470	Joint replacement (example CPT listed)
27120	Joint replacement (example CPT listed)
L0112	Orthotics/prosthetics (example HCPCS listed)

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Sample orthotics/prosthetics L-codes (partial list)HCPCS

L5420
L5460
L5500
L5505
L5510
L5520

Radiation therapy CPT/HCPCS examplesCPT | HCPCSCovered

77520	Proton beam therapy
77522
77523
77525

ENT / rhinoplasty / sinuplasty (examples)CPTCovered

30400	Rhinoplasty
30410	Rhinoplasty
30420	Rhinoplasty
30430	Rhinoplasty
31295	Sinuplasty
31296	Sinuplasty
31297	Sinuplasty
31298	Sinuplasty

Musculoskeletal / arthroscopy examplesCPTCovered

29806	Arthroscopy (example)
29807	Arthroscopy (example)
29819	Arthroscopy (example)
29822	Arthroscopy (example)

Sleep studiesCPTCovered

95805	Sleep study - unattended polysomnography
95807	Sleep study - polysomnography
95808	Sleep study
95810	Sleep study with CPAP
95811	Sleep study

Urinary system / urologic procedures (examples)CPT

52276	Urologic procedure code listed
52287	Urologic procedure code listed
52320	Urologic procedure code listed
52344	Urologic procedure code listed

Sleep study codesCPTCovered

95805	Sleep study (split-night attended polysomnography)
95807	Sleep study with initiation of CPAP
95808	Overnight sleep study
95810	Polysomnography, comprehensive
95811	Polysomnography with initiation of CPAP

Device/implant codes (examples)HCPCSCovered

E0748	External bone growth stimulator (example listing)
E0749	External bone growth stimulator
E0760	Bone growth stimulation device
L8687	Implantable neurostimulator component
L8688	Implantable neurostimulator component

Wound VAC codeHCPCSCovered

E2402

Wound VAC pump

How Providers Should Request Authorizations and Notifications

Prior Authorization

Prior Authorization Required — Procedures & Devices

Prior Authorization Required — Procedures and Devices: Prior authorization is required for the listed outpatient and inpatient procedures and implantable devices. This includes (but is not limited to) circumcision (CPT 54161), cochlear and other auditory implants (CPT 69714, 69930; HCPCS L8614, L8619, L8690–L8692), cosmetic/reconstructive procedures when indicated codes are listed (e.g., 11960, 14020, 15820–15823, 17106–17108, 17999, 21138, 21175, 21180–21184, 21230, 21235, 21256, 21275, 21280, 21282, 21295, 21740), sleep apnea surgeries and sleep studies (CPT 21685; sleep study codes 95805, 95807–95811), spinal surgery codes (e.g., 22100–22102, 22110–22114, 22206–22207, 22210, 22212, 22214, 22220, 22224, 22510–22515, 22532–22554), stimulators/neurostimulator implantation and device codes (E0748, E0749, E0760; CPT 61863, 61864, 61867, 61868, 61885, 61886, 63650, 63655, 63685, 64553–64570; HCPCS L8682–L8688), transplants and CAR T-cell therapies (HCPCS L8687–L8688 and select J/J‑codes as noted), vein procedures (CPT 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766), ventricular assist devices (CPT 33927–33929, 33975–33976, 33982–33983), wound VAC (HCPCS E2402), and other procedures/devices listed on the provider resources. Providers must obtain prior authorization before scheduling these services except when emergency/urgent care applies.

Prior authorization required for the procedures and device codes listed in this section and on UHCprovider.com/MScommunityplan resources.
Certain procedures may be site-of-service dependent; prior authorization may be required only when performed in an outpatient hospital setting.
Some CPT codes noted in the source may be exempt from prior authorization when billed with specific accompanying codes — verify code-specific guidance before submission.

Key Terms and Contacts

Prior authorization — definition & emergency exception

DefinitionPrior authorization is the requirement to get approval before certain procedures or services; prior authorization is not required for emergency or urgent care.

Out-of-network requirementOut-of-network physicians, facilities and other providers must request prior authorization for all procedures and services except emergent/urgent care.

How to requestSubmit requests online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal, or by phone (877-842-3210) or fax (888-310-6858).

Behavioral health network/provider

NetworkBehavioral health services are provided through the Optum Behavioral Health network.

How to refer

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Mississippi - Mississippi Coordinated Access Network (MississippiCAN)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateEffective Apr. 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or by phone 877-842-3210 or fax 888-310-6858.

SourceLink

On This Page

Prior Authorization

Elective/Planned and Emergent Inpatient Admissions

Elective/Planned Inpatient Admissions: Prior authorization is required for elective or planned inpatient admissions. Requests must be submitted at least 5 business days prior to the scheduled non‑urgent admission or procedure. Emergent or urgent inpatient admissions do not require prior authorization but must be reported — notification of the admission is required within 24 hours of admission.

Submit elective admission prior authorization at least 5 business days before the scheduled service.
For emergent/urgent admissions: no prior authorization required; notification required within 24 hours.

Prior Authorization

Experimental / Investigational Services

Experimental / Investigational Services: Services identified as experimental, investigational, or unproven, and any linked services, require prior authorization. Example codes listed as experimental/investigational in the source include (but are not limited to) 33477, A4226, 36514, and 64722. Requests for these services will be reviewed for medical necessity and coverage eligibility.

Prior authorization required for experimental, investigational, or unproven services and associated codes.
Clinical documentation supporting medical necessity must be submitted with the request.

Prior Authorization

Genetic / Molecular Testing Prior Authorization

Genetic and Molecular Testing: Prior authorization is required for genetic and molecular testing performed in the outpatient setting. For certain tests (for example, BRCA testing prior to DNA sequencing), the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare. Submit supporting clinical information with the prior authorization request.

Prior authorization required for outpatient genetic/molecular testing (including BRCA and similar testing).
The ordering provider must ensure the lab notifies UnitedHealthcare when required by the test workflow.

Prior Authorization

Enteral / Parenteral Services Prior Authorization

Enteral and Parenteral Services (In‑home Nutritional Therapy and Related Products): Some enteral and parenteral services require prior authorization. Certain enteral products supplied via gastrostomy or enteral routes may be priced and dispensed through pharmacy benefits and are available through contracted retail pharmacies (see Mississippi Preferred Drug List at medicaid.ms.gov). Examples of HCPCS codes requiring prior authorization include B4034, B4035, B4036 and B9002.

Prior authorization required for specified enteral/parenteral in‑home nutritional therapy products (e.g., HCPCS B4034–B4036, B9002).
Some products may be processed under pharmacy benefits and dispensed through OptumRx-contracted pharmacies — check the Mississippi PDL for covered items.

Prior Authorization

Hearing Aids and Hysterectomy — Prior Authorization

Hearing Aids and Hysterectomy: Prior authorization is required for hearing aids and for hysterectomy procedures listed in the source. Hearing aid and related service codes include 92591, 92595, V5010, V5050, V5014, V5060, V5255, V5030 and V5100. Hysterectomy procedures requiring prior authorization include CPT codes 58262, 58290, 58263, 58180 and 58260.

Prior authorization required for hearing aids (e.g., 92591, 92595; V‑series codes listed) and for hysterectomy codes (58180, 58260, 58262, 58263, 58290).
Verify device-specific or manufacturer guidance when applicable and include clinical justification with the request.

Prior Authorization

Injectable Medications & New‑to‑Market Medications Guidance

Injectable Medications and New-to-Market Drugs: Many injectable medications require prior authorization. Examples include chemotherapy injectable drugs (HCPCS J9000–J9999 and specified J/Q codes), and a long list of specialty injectable products (selected J- and Q‑codes such as J0180, J0222–J0225, J0256, J1411–J1413, J1745–J1786, J2329, J2350, J3398–J3399, Q5103–Q5130, and many others listed in the source). For injectable chemotherapy and specialty injectables, submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 888-397-8129. For unclassified or temporary codes (C9167, C9168, J3490, J3590, J9999) prior authorization may be required only for specific products as noted.

Injectable chemotherapy (J9000–J9999, leucovorin J0640–J0642, Lupron J1950/J1952, Q‑codes, and miscellaneous unassigned HCPCS) requires prior authorization.
Submit injectable medication prior authorizations online via the Provider Portal Prior Authorization and Notification tool or call 888-397-8129.
Refer to the source list for specific J/Q codes; for unclassified/temporary codes, PA applies only to certain products (see guidance).

Prior Authorization

Out‑of‑Network and Other Service Categories Requiring Prior Authorization

Out‑of‑Network Services and Other Service Categories Requiring Prior Authorization: All out‑of‑network services require prior authorization. Additional service categories that require prior authorization include radiology (advanced outpatient imaging), radiation therapy/oncology, outpatient therapies (e.g., speech therapy CPT 92507), pain injections/management (e.g., 64490, 64493), prescribed pediatric extended care (PPEC) (T2002, T1025, T1026), private duty nursing (S9122–S9124), prostate procedures (e.g., 37243, 52441–52442, 53852, 55873–55874), and other categories listed in provider resources. For radiology, select the Radiology, Cardiology, Oncology, and Radiation Therapy box in the Provider Portal to route requests appropriately; for transplant and CAR T-cell services contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246.

All out‑of‑network referrals require prior authorization (excluding emergent/urgent care).
Use the Provider Portal workflows: Radiology/Cardiology/Oncology/Radiation Therapy box for those service types; refer transplant/CAR T authorization to Optum Transplant or call the transplant case management team at 888-936-7246.
Many other service categories (listed above) require prior authorization — verify code-level requirements on UHCprovider.com/MScommunityplan resources.

For mental health and substance use services, call the number on the member's health plan ID card; ABA therapy submissions via fax or Provider Express.

Where to find detailsSee providerexpress.com > Guidelines/Policies & Manuals > State-Specific Manuals and Addendums > MS CAN Manual for additional information.

Chemotherapy (injectable)

DefinitionChemotherapy (injectable) refers to injectable chemotherapy drugs administered in an outpatient setting, including intravenous, intravesical and intrathecal agents.

Code range examplesIncludes chemotherapy injectable drugs billed under J9000–J9999, Q‑code chemotherapy agents, and miscellaneous unassigned HCPCS codes for agents without assigned codes.

Specific agents notedLeucovorin (J0640) and levoleucovorin (J0641, J0642), Lupron Depot (J1950), and leuprolide (J1952) are listed as examples requiring prior authorization.

Prior authorization — requirement for certain procedures & devices

General noteCertain procedures and medical devices listed in this document require prior authorization before services are provided.

ExamplesExamples include circumcision (CPT 54161), cochlear implants (CPT 69714, 69930; HCPCS L8614, L8619, L8690–L8692), and many procedure categories such as rhinoplasty, sinuplasty, spinal surgery, stimulators, transplants and radiation therapy.

Submission instructionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone as directed in the document.

Durable medical equipment (DME) — prior authorization

ScopeDurable medical equipment (DME) prior authorization applies only to the specific DME HCPCS codes listed in the document.

Examples of listed DME codesA6549, A9280, A9900, B4152, B4161, E0194, E0265, E0266 (listed as requiring prior authorization).

Cumulative rental noteSome DME entries reference cumulative rental cost thresholds for outpatient equipment (see E0270, E0277, E0300 entries).

Prior authorization exception — select CPT codes

Exception summaryCertain CPT codes (67950, 67961, 67966) may not require prior authorization when billed with specified accompanying codes (document notes prior authorization not required in those combinations).

Codes referencedCPT codes 67950, 67961, 67966 are specifically called out in the exception note.

ContextThe document indicates these exceptions apply only when billed with the specified accompanying code(s); review claim detail for applicability.

Prior authorization timing — elective vs emergent admissions

Elective/planned admissions timingPrior authorization is required at least 5 business days prior to non-urgent, elective or planned inpatient admissions.

Emergent/urgent admissionsPrior authorization is not required for urgent or emergent inpatient admissions, but notification of the admission is required within 24 hours.

How to notifyFollow the document's notification instructions and use Provider Portal or phone/fax methods as appropriate for admission notifications.

Experimental / investigational services — prior authorization

RequirementServices identified as experimental or investigational (and linked services) require prior authorization.

Examples citedExperimental/investigational entries reference specific CPT/HCPCS examples (e.g., 33477, A4226, 36514, 64722) in the document.

ActionSubmit prior authorization requests for these services via the Provider Portal per the document instructions.

Prior authorization — submission methods

Primary submission methodOnline: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

PhonePhone numbers referenced for prior authorization/assistance include 877-842-3210, 888-397-8129 and 866-889-8054 depending on the service listed.

FaxFax prior authorization requests to 888-310-6858 where applicable.

Proton Beam — definition / authorization

DefinitionProton Beam is focused radiation therapy that uses beams of protons (tiny particles with a positive charge).

Codes listedCPT/HCPCS examples associated with proton beam therapy include 77520, 77522, 77523, 77525 and related radiation therapy service codes (e.g., 77331, 77370, 77399, 77470).

AuthorizationPrior authorization is required for radiation therapy services as listed; submit via Provider Portal per radiation authorization instructions.

UnitedHealthcare Provider Portal — Prior Authorization & Notification tool

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

How to accessGo to UHCprovider.com, click the UnitedHealthcare Provider Portal button, then select the Prior Authorization and Notification tool on the dashboard to submit requests.

Service-specific routingFor Radiology/Cardiology/Oncology/Radiation Therapy select the corresponding box; some flows direct to another website to process authorization requests.

Site of service (SOS) — outpatient hospital authorization guidance

SOS guidanceSite of service (SOS) — Outpatient hospital: prior authorization is required when requesting the service in an outpatient hospital setting.

ASC exceptionPrior authorization is not required if the service is performed at a participating Ambulatory Surgery Center (ASC), per the document notes.

Provider responsibilityCare providers ordering advanced outpatient imaging must provide notification prior to scheduling the procedure and follow radiology prior authorization routing.

Transplant case management team — contact

Transplant case management contactUnitedHealthcare Community and State Transplant Case Management Team — call 888-936-7246 (or use the notification number on the back of the member's health plan ID card).

When to contactContact the team for transplant and CAR T‑cell therapy services (Abecma®, Breyanzi®, Kymriah™, Tecartus™, Yescarta®, etc.).

Authorization requirementTransplants and CAR T‑cell therapy services require prior authorization; follow the document's specified routing to Optum Transplant where applicable.

General requirement — services requiring pre‑service prior authorization (summary)

General requirementMultiple categories of procedures, devices and services require pre‑service prior authorization as listed in the document (examples below).

Selected categoriesInjectable chemotherapy; injectable medications; DME (listed codes only); radiation therapy and proton beam; radiology advanced outpatient imaging; transplants and CAR T; stimulators/neurostimulators; spinal surgery; vein procedures; wound VAC; ENT procedures (rhinoplasty, sinuplasty); sleep studies; private duty nursing and PPEC; out‑of‑network services.

Submission and timingSubmit authorizations via the Provider Portal Prior Authorization and Notification tool (or use service‑specific phone/fax numbers). Elective/planned inpatient admissions require authorization at least 5 business days prior; emergent admissions require 24‑hour notification.