CurrentUnitedHealthcarePolicy N/A

Advance prior authorization requirements for Neighborhood Health Partnership

This document lists prior authorization review requirements for participating Neighborhood Health Partnership (NHP) plan health care professionals providing inpatient and outpatient services; it explains how to submit requests and notes exceptions for emergency or urgent care and out-of-network providers.

Policy Summary

PayerUnitedHealthcare

PolicyAdvance prior authorization requirements for Neighborhood Health Partnership

Policy CodePolicy N/A

Change TypeNo material change

Effective DateEffective August 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online/Chatmethods to submit

Many servicesadvance PA required

Emergency/Urgentexemptions

$1,000DME PA threshold

J9000-J9999injectable chemo

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Advance Prior Authorization Coverage Criteria

Prior authorization coverage stance

Advance prior authorization is required for many procedure and service categories. Emergency or urgent in- and out-of-area care do not require advance prior authorization. Out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care. Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, chat 24/7, or by phone where noted.

Prior authorization is required for the procedure and service categories listed in this policy for all Neighborhood Health Partnership (NHP) plan members in both outpatient and inpatient settings, unless otherwise noted.

Advance prior authorization is not required for emergency or urgent in- and out-of-area care.

Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services, excluding emergent or urgent care.

To submit prior authorization requests:

- Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Sign in with a One Healthcare ID. If you do not have a One Healthcare ID, visit UHCprovider.com/access to register.

- Chat: Connect through chat 24/7 using the Contact us page on UHCprovider.com.

- Phone: For some categories or where specified in this policy, phone numbers or notification numbers on the member's health plan ID card may be used to start case management or authorization (see category-specific notes).

Informational notices

Administrative and trademark notices relevant to coding and documentation.

CPT is a registered trademark of the American Medical Association.

This policy references CPT and HCPCS codes and diagnosis codes; confirm coding and modifier requirements at time of submission.

Reference documents and clinical quick-reference guides cited in this policy (when listed) should be used to support clinical rationale in the authorization request.

No coverage criteria in this segment

Some items in this segment explicitly state that no prior authorization is required for specified diagnoses or situations. These exceptions must be observed when applicable.

Prior authorization not required for the listed breast cancer and related diagnosis codes (examples include many C50 and D05 series codes) when the policy text or category entry states 'Prior authorization not required for the following diagnosis.'

Certain anti-emetic and supportive cancer care medications may have separate prior authorization requirements — check the specific injectable medication lists when the cancer diagnosis entry indicates exceptions.

When the policy lists 'Prior authorization not required for the following diagnosis' for a code series, that code-level exception overrides a general code-based prior authorization requirement for the same CPT/HCPCS code when billed with the specified diagnosis.

If an item in this segment lacks an associated coverage criterion or code list, treat it as: no additional authorization requirement beyond standard clinical and benefit verification, but always verify member benefits and network requirements prior to rendering services.

Relevant CPT/HCPCS/ICD-10 Codes

Covered CPT CodesCPTCovered

27412	Cartilage implant procedure
27415	Cartilage implant procedure
27416	Cartilage implant procedure
29866	Arthroscopy, shoulder, with implantation
29867	Arthroscopy, shoulder, with implantation
29868	Arthroscopy, shoulder, with implantation
31240	Nasopharyngoscopy, or related endoscopy
31253	Nasal/sinus endoscopy, with biopsy or foreign body removal
31254	Nasal/sinus endoscopy, with ethmoidotomy
31255	Nasal/sinus endoscopy, with maxillary antrostomy

1–10 of 31

1/4

CPT EEG / Monitoring Codes (Require Authorization)CPTCovered

95700	EEG monitoring, standard
95711	EEG monitoring, continuous
95712	EEG monitoring, continuous
95713	EEG monitoring, continuous
95714	Inpatient video EEG monitoring
95715	Inpatient video EEG monitoring
95716	Inpatient video EEG monitoring
95718	Inpatient video EEG monitoring
95720	Electroencephalogram (EEG) routine
95722	Electroencephalogram extended

1–10 of 12

1/2

Chemotherapy/J- Codes Requiring AuthorizationmixedCovered

J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin, alternate
J1932	Lanreotide
J1950	Leuprolide acetate
J1952	Leuprolide
J7330	Injection, hyaluronan for intra-articular (hyaluronic acid)
J9000-J9999	Chemotherapy injectable drugs (J9000 - J9999)
J7330	Hyaluronan injection (listed for cartilage implant context)

How to Obtain Prior Authorization and Provider Responsibilities

Prior Authorization

Submit PAs via Provider Portal or 24/7 chat; emergency/urgent care exempt

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) by signing in with a One Healthcare ID, or connect via 24/7 chat on the Contact us page. Advance prior authorization is not required for emergency or urgent in- and out-of-area care; out-of-network clinicians must request prior authorization for all procedures and services except emergent or urgent care.

Online: Prior Authorization and Notification tab after signing in with One Healthcare ID (UHCprovider.com).
Chat: 24/7 via the Contact us page.
Emergent/urgent care is exempt from advance prior authorization.
Out-of-network providers must request prior authorization for non-emergent services.

Prior Authorization

How to obtain prior authorization (portal and phone numbers)

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). For general prior authorization assistance call 888-397-8129; for cardiology prior authorization call 866-889-8054.

Key Terms and Definitions

inv-71: Advance prior authorization is a review requirement for specified procedures and services that must be requested before non-emergent care.

DefinitionAdvance prior authorization is a review requirement for specified procedures and services that must be requested before non-emergent care.

ApplicabilityRequired for listed procedure and service categories for all NHP plan members in both outpatient and inpatient settings, unless otherwise noted.

Exemption noteNot required for emergency or urgent in- and out-of-area care.

inv-72: Care for which advance prior authorization is not required (in- and out-of-area).

Not required forEmergency or urgent in- and out-of-area care (advance prior authorization not required).

Out-of-network clinicians

Policy Summary

PayerUnitedHealthcare

PolicyAdvance prior authorization requirements for Neighborhood Health Partnership

Policy CodePolicy N/A

Change TypeNo material change

Effective DateEffective August 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat.

SourceLink

On This Page

Portal: UHCprovider.com → Sign In → Prior Authorization and Notification tab.
General phone: 888-397-8129.
Cardiology phone: 866-889-8054.

Prior Authorization

Denosumab and colony-stimulating factors require PA

Denosumab (Prolia, Xgeva) and certain colony-stimulating factor products require prior authorization for outpatient administration; some Q-codes also require prior authorization for non-oncology diagnoses.

Denosumab requires prior authorization (Denosumab: Prolia®, Xgeva®).
Multiple colony-stimulating agents (e.g., eflapegrastim J1449 and related Q-codes) have prior authorization rules; some are noted as not required for specific oncology diagnoses but require authorization for non-oncology DX.

Prior Authorization

Cardiology/CV procedures require prior authorization

Participating physicians must obtain prior authorization for outpatient and office-based diagnostic catheterizations, electrophysiology implants, echocardiograms and stress echoes; see the Cardiology Prior Authorization and Notification resource for detailed CPT codes.

Cardiology PA submissions: use the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054.
Prior authorization is required prior to performance for the listed cardiology procedures.

Prior Authorization

PA required for congenital heart disease services; start via chat or member ID notification

Prior authorization is required for congenital heart disease and congenital heart disease–related services, including pre-treatment evaluation; initiate authorization via 24/7 chat on the Contact us page or by using the notification number on the member's health plan ID card (or call 888-397-8129).

Services (examples include CPT codes 33250–33261 and 33390) are listed as prior authorization required.
Start case management/PA via chat 24/7 or the notification number on the member ID card; phone: 888-397-8129.

Prior Authorization

PA requirements for cartilage implants, monitoring; outpatient EEG excluded

Follow the code-specific prior authorization guidance: cartilage implants and certain monitoring services require prior authorization, while outpatient EEG at hospital or ASC does not require prior authorization; check listed CPT/HCPCS/J-codes for each service.

Cartilage implants (e.g., 27412, 27415, 27416, 29866–29868) — prior authorization required.
Cerebral seizure monitoring (e.g., 95700–95718) — prior authorization required for specified inpatient monitoring codes; inpatient video monitoring codes listed.
EEG outpatient hospital or ASC — prior authorization not required.

Prior Authorization

Outpatient injectable chemotherapy requires prior authorization

Injectable chemotherapy drugs administered in outpatient settings require prior authorization, including chemotherapy J-codes (J9000–J9999) and listed agents (e.g., J0640–J0642, J1950, J1952, J1932); miscellaneous/new injectable chemotherapy billed under miscellaneous HCPCS also require prior authorization.

Includes IV, intravesical and intrathecal outpatient administration.
Submit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Prior Authorization

PA required for cochlear and auditory implants; call 888-397-8129

Cochlear and other auditory implants require prior authorization; listed CPT/HCPCS codes include 69710, 69714, 69930 and HCPCS L8614, L8619, L8690–L8692. For authorization, call 888-397-8129 or connect via the Contact us page chat.

CPT codes: 69710, 69714, 69930; HCPCS: L8614, L8619, L8690–L8692.
Contact for PA: 888-397-8129 or 24/7 chat.

Prior Authorization

Start prior authorization via 24/7 chat or member ID notification

Connect via 24/7 chat on the Contact us page or use the notification number on the member's health plan ID card to start prior authorization and case management; prior authorization is required for listed services.

Use chat 24/7 or the member ID notification number to initiate prior authorization.
The policy reiterates that prior authorization is required for many listed services.

Prior Authorization

Cosmetic and reconstructive procedures require PA (all states)

Prior authorization is required for cosmetic and reconstructive procedures in all states; the policy lists numerous CPT codes that require prior authorization (examples include 11960, 14020, 15570, 15730, 15820).

Prior authorization is required for cosmetic/reconstructive procedures for all states.
Refer to the listed CPT codes in the policy when submitting PA requests.

Documentation Required

Include listed CPT codes when requesting PA for cosmetic/reconstructive services

When submitting for cosmetic and reconstructive procedures, include the specific CPT codes listed in the policy; prior authorization is required and the policy provides code-level detail (e.g., 11960, 14020*, 15574).

Include the listed CPT codes when requesting prior authorization for cosmetic/reconstructive services.
Some codes in the list have an asterisk and additional information — review the policy detail.

Denial Risk

Site-of-service will be reviewed during PA; certain diagnoses exempt

Prior authorization for listed codes will include a site-of-service review except in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin; some codes are exempt from PA when billed with specified diagnosis codes.

Site-of-service will be reviewed as part of PA for the listed codes except in the specified jurisdictions.
Certain diagnosis codes listed in the policy exempt PA for specific codes (see policy code/diagnosis lists).

Billing Rule

DME PA required when cost > $1,000; some items always require PA

Prior authorization is required only for DME codes listed with a retail purchase or cumulative rental cost greater than $1,000; pneumatic compressors and certain DME items require prior authorization regardless of cost.

DME threshold triggering PA: purchase or cumulative rental cost > $1,000.
Pneumatic compressors and some DME require PA regardless of cost.

Prior Authorization

PA required for EGD, capsule endoscopy, diagnostic/surveillance colonoscopies

Prior authorization is required for esophagogastroduodenoscopies (EGD), capsule endoscopies and diagnostic and surveillance colonoscopies for participating physicians; capsule and related CPT/HCPCS codes are listed in the policy.

EGD and capsule endoscopy PA applies to participating physicians.
Capsule endoscopy and related codes (e.g., 31253, 31257, 31287, 91113) are included in the list.

Prior Authorization

PA note: EGD and capsule endoscopy require PA for participating physicians

Prior authorization is required for participating physicians for EGD and capsule endoscopies (policy note reiterating the PA requirement for these GI procedures).

This is a reiteration that PA is required for participating physicians performing EGD and capsule endoscopies.

Prior Authorization

PA required for diagnostic/surveillance colonoscopies; screening colonoscopies excluded

Prior authorization is required for participating physicians for EGD, capsule endoscopies, and diagnostic and surveillance colonoscopies; screening colonoscopy procedures are excluded from this new medical necessity review requirement.

Diagnostic and surveillance colonoscopies require PA for participating physicians.
Screening colonoscopy procedures are not included in this requirement.

Billing Rule

Policy references many CPT/HCPCS codes — include listed codes in PA

The policy references CPT® and HCPCS codes repeatedly (examples include 43249, 43250, 43251, 43254, 43255); use the policy's code lists when preparing prior authorization requests.

Examples of referenced codes: 43249, 43250, 43251, 43254, 43255.
Review the policy’s code references to ensure correct coding on PA submissions.

Documentation Required

Confirm CPT/HCPCS placeholders and asterisk notations before submission

The document contains repeated CPT/HCPCS code placeholders (e.g., 43250, 43251, 43255) and asterisk notations; confirm exact codes and any modifiers per the policy when submitting authorization requests.

Placeholders such as 43250/43251/43255 appear with repeated asterisk notation in the policy.
Confirm the exact code and any notation before submitting PA.

Note

CPT/HCPCS trademark and informational notices (no PA actions)

This section provides general CPT/HCPCS trademark and coding boilerplate; it does not change prior authorization requirements but is informational only.

Contains repeated trademark notice: 'CPT® is a registered trademark of the American Medical Association.'
No authorization actions specified in this excerpt.

Note

CPT/HCPCS trademark notice (informational)

Boilerplate reiterating that CPT is a registered trademark of the American Medical Association; informational only and not a PA requirement.

Repeated trademark language appears throughout the document.
No clinical or authorization actions in this segment.

Prior Authorization

Submit PAs via Provider Portal or call 866-889-8054; predetermination for some IV drugs

Please submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 for assistance; use the portal Predetermination process for certain IV/infused drugs as noted.

Portal: UHCprovider.com → Sign In → Prior Authorization and Notification tab.
Phone assistance: 866-889-8054.
Submit predetermination for certain IV injectable drugs as directed in policy.

Prior Authorization

Examples: genetic testing, some hysterectomies, home health may require PA/notification

Certain services require prior authorization or notification as noted (examples include genetic/molecular testing, specified inpatient hysterectomy procedures, and some home health services); follow the policy examples for service-specific PA requirements.

Genetic/molecular testing codes (e.g., 81162, 81401) may require prior authorization.
Some inpatient hysterectomy procedures require PA; outpatient vaginal hysterectomies may not require PA for coverage.

Denial Risk

Some codes require PA only with specific diagnosis codes

Some codes only require prior authorization when submitted with specific diagnosis codes (for example, certain gender dysphoria–related procedures require notification or prior authorization when billed with diagnosis codes F64.0–F64.2).

Gender dysphoria–related services: notification or prior authorization required; specific procedures require PA when submitted with F64.0–F64.2.
Review policy notes indicating codes that are diagnosis-dependent for PA.

Prior Authorization

Submit predetermination for certain IV injectable drugs via Provider Portal

Use the Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit predetermination requests for certain IV injectable drugs; the policy lists example injectable drug codes and directs providers to the portal.

Examples of injectable codes referenced: J0517, J2182, J2356, J2357, J2786.
Submit predetermination via the Provider Portal as instructed.

Prior Authorization

Alpha1‑proteinase inhibitors require prior authorization

Alpha1‑proteinase inhibitors are noted in the policy and prior authorization is required for these injectable medications (example HCPCS/Codes include J0256 and J0257).

Alpha1‑proteinase inhibitors listed with codes J0256 and J0257.
Policy statement: 'Prior authorization required.'

Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services, excluding emergent or urgent care.

Submission methodsRequests may be submitted online (Provider Portal) or via 24/7 chat; these methods apply for non-exempt cases.

inv-73: Injectable colony-stimulating factors

Examples of agentsColony-stimulating factors and supportive agents listed include pegfilgrastim (Q5101, Q5110, Q5111, Q5122, Q5125/Q5126), filgrastim biosimilars and eflapegrastim (J1449).

Prior authorization notesSome colony-stimulating factor products require prior authorization for non-oncology diagnoses (specific Q-codes listed).

StatusThese injectable supportive care agents are included in the policy's drug/code listings and have mixed prior authorization requirements depending on diagnosis.

inv-74: Denosumab (Prolia, Xgeva)

Agent(s)Denosumab (Prolia, Xgeva) is identified as a bone-modifying agent that requires prior authorization.

Related codesQ5111, Q5120, Q5122, Q5125 and Q5126 also require prior authorization for non-oncology diagnoses as noted.

ContextDenosumab is listed in the Bone-modifying agent section with explicit prior authorization requirement.

inv-75: Cochlear and other auditory implants

RequirementCochlear and other auditory implants require prior authorization.

Example CPT/HCPCS codesListed example codes include 69710, 69714, 69930 and HCPCS L8614, L8619, L8690–L8692 (per code lists in the policy).

ContactFor prior authorization connect via chat 24/7 or call the notification number (888-397-8129) as provided in policy.

inv-76: Congenital heart disease services

RequirementPrior authorization required for congenital heart disease and congenital heart disease–related services, including pre-treatment evaluation.

Example CPT codesExamples of listed CPT codes include 33250–33261 and 33390 (additional related codes are enumerated throughout the congenital heart sections).

How to obtainInitiate prior authorization via 24/7 chat on the Contact Us page or the notification number on the member's health plan ID card (phone 888-397-8129).

inv-77: Chemotherapy services (injectable)

RequirementPrior authorization required for outpatient injectable chemotherapy drugs administered in outpatient settings (includes J9000–J9999 range and listed J-codes such as Leucovorin and others).

Administration routes includedIncludes intravenous, intravesical and intrathecal administration; miscellaneous/new injectable chemo billed under miscellaneous HCPCS also require prior authorization.

Submission instructionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

inv-78: How to Obtain Prior Authorization

Primary submission pathSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) via One Healthcare ID.

Alternate contact methodsConnect via 24/7 chat on the Contact Us page or call the listed numbers where provided (e.g., 866-889-8054 for general portal help; 888-397-8129 appears for some services).

When to submitAdvance prior authorization must be requested before non-emergent care for listed services; emergency/urgent care is exempt.

inv-79: Prior authorization required (cosmetic/reconstructive)

RequirementPrior authorization is required for cosmetic and reconstructive procedures for all states.

ExamplesListed CPT examples include 11960, 11970, 11971, 14020, 14021, 14061, 14302, 15570, 15572, 15574 and others noted in the cosmetic/reconstructive section.

ApplicabilityApplies to the CPT/HCPCS codes enumerated in the cosmetic and reconstructive procedures section unless otherwise specified.

inv-80: Prior authorization

General definitionPrior authorization: an approval process required in advance for specified procedures and services before non-emergent care.

ExemptionNot required for emergency or urgent in- and out-of-area care.

Submission methodsRequests submitted via the Provider Portal, chat, or designated phone numbers as noted in the policy.

inv-81: Durable Medical Equipment (DME) prior authorization

Trigger thresholdPrior authorization required for DME items with a retail purchase or cumulative rental cost exceeding $1,000.

Always-authorize itemsPneumatic compressors and certain other DME require prior authorization regardless of cost.

Example HCPCS codesExamples shown in the DME section include A7025, E0265 and multiple E0XXX/K08XX codes.

inv-82: Prior Authorization (participating physicians)

Participating physicians requirementPrior Authorization required for participating physicians for specified outpatient procedures (e.g., diagnostic catheterizations, electrophysiology implants, echocardiograms and stress echoes).

Cardiology contactCardiology prior authorization details and codes are available via the Cardiology Prior Authorization and Notification program on the portal; phone contact listed in policy references (866-889-8054 for portal assistance; 888-397-8129 for some services).

Codes examplesExample procedure codes referenced in cardiology sections include 33285, 37220–37226, 93580 and others enumerated in the policy.

inv-83: Screening Colonoscopy exclusion

ExclusionScreening colonoscopy procedures are not included in this new medical necessity review requirement (screening colonoscopy codes such as 44388, 44389, 44392, 44394 and related codes are noted as excluded from the requirement).

Related SOS noteSite-of-Service (SOS) considerations may apply to colonoscopy screening codes (G0105, G0121) per policy notes.

ApplicabilityDiagnostic and surveillance colonoscopies remain subject to prior authorization for participating physicians as detailed elsewhere in the document.

inv-84: CPT®

Trademark noticeCPT® is a registered trademark of the American Medical Association.

Document identifierDocument/tracking identifier referenced: PCA-3-24-01315-Clinical-QRG_07182024 appears in the general information sections.

BoilerplateRepeated CPT/HCPCS trademark and acknowledgment language appears throughout the policy's informational sections.

inv-85: PCA-3-24-01315-Clinical-QRG_07182024

Document IDPCA-3-24-01315-Clinical-QRG_07182024 is included as the document/tracking identifier in the policy's general information and trademark sections.

ContextReferenced alongside CPT/HCPCS trademark notices in the informational boilerplate portions of the document.

inv-86: CPT trademark notice

Notice text'CPT® is a registered trademark of the American Medical Association' — trademark notice repeated throughout the policy document.

PlacementAppears in multiple informational sections and code reference boilerplate.

PurposeInformational/legal acknowledgment regarding CPT coding references in the policy.

inv-87: CPT / HCPCS trademark notice

Combined trademark noticeReferences to CPT and HCPCS trademark/acknowledgment language appear together in the document's informational sections.

Repeated boilerplateThis trademark/notice language is repeated numerous times across the policy text.

inv-88: CPT trademark notice

CPT trademarkCPT is a registered trademark of the American Medical Association — statement repeated in policy boilerplate.

Informational onlyThese lines are informational and do not impose coverage actions.

inv-89: CPT trademark notice

Trademark repetitionCPT trademark acknowledgement ('CPT is a registered trademark of the American Medical Association') repeated in multiple sections of the document.

Document ID pairingTrademark lines often appear adjacent to the document identifier PCA-3-24-01315-Clinical-QRG_07182024.

inv-90: CPT® / HCPCS trademark notice

Trademark acknowledgementCPT® and HCPCS references include repeated trademark statements acknowledging AMA ownership of CPT®.

Informational natureThese are boilerplate legal/copyright notices and do not change authorization rules.

inv-91: CPT/HCPCS trademark

Trademark statementCPT and HCPCS are referenced with trademark acknowledgements multiple times in the policy document.

UsageUsed in general information and code reference sections as legal acknowledgment when listing CPT/HCPCS codes.

inv-92: Prior authorization / notification

Submission methodsPlease submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Alternate contactsPortal help/phone: 866-889-8054; some services list 888-397-8129 for prior authorization questions; 24/7 chat available via Contact Us page.

Predetermination instructionFor certain IV injectable drugs, submit a predetermination via the Authorization and Notification tool as specified in the drug sections.

inv-93: Site of Service (SOS)

Site-of-service (SOS)Site-of-Service considerations may apply to certain procedures (e.g., colonoscopy screening codes G0105/G0121 have SOS notes).

Screening colonoscopy noteScreening colonoscopy procedures are excluded from the new medical necessity review requirement, but SOS may still apply to site-specific billing rules.

Portal instructionWhen SOS rules apply, include applicable documentation when submitting prior authorization via the Provider Portal.

inv-94: Prior authorization

DefinitionPrior authorization is an approval process that must be obtained in advance for specified procedures and services before non-emergent care.

How to submitUse the Prior Authorization and Notification tool on UHCprovider.com, chat 24/7, or call portal phone numbers as listed per service.

ExemptionEmergency and urgent care are exempt from advance prior authorization requirements.

inv-95: Immune globulin

Definition/termImmune globulin and related infusion therapies are listed with example CPT/HCPCS/J-codes (e.g., 90283, 90284, J1555, J1561, J1572) in the policy's drug sections.

Prior authorization noteImmune globulin products are included among injectable medications for which authorization/predetermination guidance is provided (see drug-specific sections).

Submission guidanceFor certain infused/injected products, the policy directs use of the Authorization and Notification tool or predetermination submission via the Provider Portal.