Prior authorization requirements for Ohio Medicaid
Lists services, CPT/HCPCS/ICD-10 codes, and instructions for submitting prior authorization requests for UnitedHealthcare Community Plan of Ohio providers. Applies to participating providers delivering inpatient and outpatient services in Ohio Medicaid.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Ohio 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 877-842-3210.
No material clinical or coverage changes in this revision.
Online portalsubmission method
877-842-3210phone to request PA
Apr 1, 2024effective date
Excludedemergency/urgent care
Multiple listscode listings
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$500
DME/orthotics threshold
Services and Coverage Criteria Requiring Prior Authorization
Cancer supportive care prior authorization criteria — Cancer supportive care medications
Prior authorization requirements and coverage criteria for cancer supportive care medications and related injectable chemotherapy and supportive agents.
For outpatient administration of colony-stimulating factor (CSF) drugs, erythropoiesis-stimulating agents (ESAs), and bone-modifying agents for a cancer diagnosis, prior authorization is required.
Specific HCPCS/J-codes that require prior authorization (examples listed in source): J1449 (eflapegrastim-xnst, Rolvedon®), J1442 (filgrastim, Neupogen®), Q5110 (filgrastim-aafi, Nivestym™), Q5125 (filgrastim-ayow, Releuko®), Q5101 (filgrastim-sndz, Zarxio®).
White blood cell colony-stimulating factor codes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 and Q5125 require prior authorization for non-oncology diagnoses as well as oncology diagnoses; follow the guidance in the Cancer supportive care section for oncology DX.
Injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis require prior authorization. This includes: chemotherapy injectable drugs billed under J9000–J9999, leucovorin (J0640) and levoleucovorin (J0641, J0642), Lupron Depot (J1950), leuprolide (J1952), drugs billed with Q-codes, and miscellaneous HCPCS codes for newly coded agents.
For prior authorization submission: use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and select the Prior Authorization and Notification tile; phone support numbers (varied in source) are provided for certain programs — consult the Provider Portal for the correct phone number for the requested service.
Unclassified/temporary codes (e.g., C9160, C9162, C9167, C9168, J3490, J3590) may require prior authorization only for specified products; check the Review at Launch Medication List and provider resources for up-to-date requirements.
New-to-market medications are tracked on the Review at Launch for New to Market Medications list; pre-determination (prior authorization) is highly recommended for drugs on that list.
Surgical services prior authorization criteria — Surgical procedures and other listed services
Surgical services and procedures that require prior authorization. The list below highlights procedure categories and representative CPT codes; review the Provider Portal for full code lists and site-of-service rules.
Joint replacement (total hip and knee) procedures require prior authorization. Representative CPT codes include 27120, 27125 and related joint replacement procedure codes.
Spinal surgery procedures require prior authorization. Representative CPT codes include 22100, 22101, 22102, 22110, 22112, 22114 and related codes.
Prior authorization coverage criteria (excerpt) — Coverage stance and criteria for selected services in this excerpt.
Prior authorization coverage stance and specific criteria excerpt for selected services (chemotherapy, video EEG, genetic testing, home health, DME, enteral nutrition). Consolidated operational points and code examples follow.
Chemotherapy: Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis, including IV, intravesical and intrathecal routes. Applicable codes include J9000–J9999, leucovorin (J0640), levoleucovorin (J0641, J0642), Lupron Depot (J1950), leuprolide (J1952), and Q-codes. Also includes chemotherapy drugs billed under miscellaneous HCPCS when an assigned code is not yet available.
Cerebral seizure monitoring / video EEG: Prior authorization required for inpatient video EEG CPT codes 95700, 95711–95713, 95714–95718, 95720–95726; note inpatient services may require authorization while outpatient/ASC settings may not.
Genetic and molecular testing (including BRCA): Prior authorization is required. Representative CPT codes: 81162–81164, 81228–81229, 81277, 81400–81406, 81522, 81546, 81595, 81599 and others. Notification/prior authorization is required for BRCA testing before DNA sequencing is performed; ordering provider and lab notification workflows apply.
Home health care: Prior authorization is required only in outpatient settings including the member's home. Representative HCPCS: G0151–G0153, G0156, G0299–G0300.
PA coverage criteria (excerpt) — Coverage stance and authorization requirements for listed services and codes in this excerpt.
Operational prior authorization requirements — when authorization is required, how to obtain it, and special routing notes for selected categories.
General submission: For most services requiring prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and select the Prior Authorization and Notification tile. Phone numbers for prior authorization and specialized programs are available on the Provider Portal.
Prior authorization required regardless of billed amount: Many DME items require prior authorization regardless of billed amount — verify code-specific rules on the Provider Portal. Certain orthotics/prosthetics and DME require authorization only if retail purchase or cumulative rental cost > $500 (codes K0886, K0890, K0891 noted).
Special programs and routing: Transplant and CAR T-Cell therapy services require calling the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 (or the notification number on the member's ID card) and may require routing through Optum Transplant for select gene therapies. Ventricular assist devices (VAD) require contacting Optum VAD Case Management and faxing forms to 855-282-8929 as instructed.
Drug-specific routing: New-to-market medications and certain unclassified/temporary codes (C9160, C9162, C9167, C9168, J3490, J3590) have special prior authorization rules — check the Review at Launch Medication List and follow the Provider Portal guidance. For Solaris, prior notification via OptumRx prior notifications services at 800-310-6826 is noted.
Prior authorization requirements (partial) — Items subject to prior authorization or notification as indicated.
Partial prior authorization requirements for injectable medications and specialty drugs — submission expectations and notable code lists.
Many injectable medications require prior authorization. Representative examples and J-/Q-codes from the source include but are not limited to: J0584 (Crysvita®), J0567 (Brineura™), J2329 (Briumvi®), J0741 (Cabenuva™), J0598 (Cinryze®), J0802 (Cortrophin™ Gel), J0589 (Daxxify), J1743 (Elaprase®), J3060 (Elelyso®), J2327, J1602 (Skyrizi®), J7320–J7332 (sodium hyaluronate codes), J1300 (Soliris®), J1930 (Somatuline® Depot), J2327, J1823 (Uplizna®), J9376 (Veopoz), J1427 (Viltepso™), J1322 (Vimizim®), J3032 (Vyepti™), J3401 (Vyjuvek™), J1429 (Vyondys 53®), J9332 (Vyvgart™), J9334 (Vyvgart Hytrulo).
Review at Launch and unlisted codes: Drugs on the Review at Launch Medication List should be pre-determined; unclassified codes (C9160, C9162, C9167, C9168, J3490, J3590) may be prior authorized only for specified products — consult the Provider Portal for product-specific routing.
Submission channel: Prior authorization requests for injectable medications should be submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by calling the designated phone numbers when specified.
Special notes: Some agents (e.g., Solaris) require prior notification via OptumRx prior notification services; follow the drug-specific instructions in the Provider Portal and specialty program guidance.
Prior authorization-required services (excerpt) — Services and codes in this section require prior authorization.
Prior authorization-required services (excerpt) — categories and representative CPT/HCPCS codes that require authorization and routing instructions for submission.
Outpatient therapy services: Prior authorization may be required for selected outpatient therapy CPT codes (examples listed in source include 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032–97039, 97110–97116, 97124, 97129, 97139–97150, 97169–97172, 97530, 97533, 97535–97537, 97542, 97545–97546, 97750, 97755, 97761, 97763). Verify codes on Provider Portal.
Prostate procedures: Prior authorization required for selected CPT codes such as 37243, 52441, 52442, 53850, 53852, 55873, 55874.
Radiation therapy: Prior authorization required. Representative CPT/HCPCS include IGRT 77014 and radiation therapy planning/associated services codes (e.g., 77331, 77370, 77399, 77520–77525). Proton therapy and special/associated services may have specific prior authorization rules.
Prior authorization criteria excerpt — Site-of-service rules apply where noted.
Prior authorization criteria excerpt — operational notes, site-of-service rules, and special routing for transplants, CAR T-cell therapies, and gene therapies.
Submission for prior authorization: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal; phone numbers such as 866-889-8054 or other program-specific numbers are listed in source guidance — consult the Provider Portal for correct contact information.
Transplants and CAR T-Cell therapies: Prior authorization required. For transplant and CAR T-Cell therapies (Abecma®, Breyanzi®, Kymriah™, Tecartus™, Yescarta™ and others), call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or the notification number on the member’s ID card; some gene therapies require routing through Optum Transplant.
Unclassified/temporary codes and Optum Transplant routing: Certain products billed under unclassified/temporary or miscellaneous codes (C9399, J3490, J3590, and other unclassified codes) may require prior authorization through Optum Transplant (examples include Casgevy, Lantidra, Lyfgenia, Skysona™, Zynteglo™).
Site-of-service (SOS) rules: Prior authorization may be required only when services are requested at specific sites (e.g., outpatient hospital). For services performed at a participating Ambulatory Surgery Center (ASC), authorization rules may differ — verify per-code SOS rules on the Provider Portal.
Prior authorization coverage criteria (section excerpt) — Categories and codes that require prior authorization; special routing/limitations noted.
Prior authorization coverage criteria (section excerpt) — additional device, transplant, and vascular procedure requirements and routing instructions.
Transplant and gene therapy products: Certain gene therapies and cell-based therapies (Casgevy, Lantidra, Lyfgenia, Skysona™, Zynteglo™ and others) require prior authorization through Optum Transplant; these may be billed under unclassified/temporary HCPCS or J-codes (e.g., C9399, J3490, J3590).
Ventricular assist devices (VAD): Prior authorization required. Contact the notification number on the member's health plan ID card and fax required forms to the Optum VAD Case Management team at 855-282-8929. Representative CPT/HCPCS include 33927, 33976, 33928, 33979, Q0507, 33929, 33981, 33975, 33982, Q0509.
Vein procedures and saphenous trunk ablation: Prior authorization required for selected CPT codes such as 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766, 37780 and related codes for treatment of venous disease and varicose veins.
Stimulators and implantable devices: Prior authorization required for implantation of stimulators and similar devices (example CPT 64590 and related codes). Some orthotics/prosthetics authorization thresholds (retail purchase or cumulative rental > $500) apply to specific L/K codes; check Provider Portal for exact thresholds.
CPT / HCPCS / ICD-10 Code Listings
Surgical CPT code groupsCPT
59840-59857
Abortion - pregnancy termination CPT range examples
prior authorization required only for oncology diagnosis
36473
vein procedure
36475
vein procedure
36478
vein procedure
37700
vein procedure
37718
saphenous removal/ablation
37722
saphenous removal/ablation
37765
saphenous removal/ablation
37766
saphenous removal/ablation
37780
saphenous branches treatment
1–10 of 20
1/2
inv-36: Cancer outpatient administration — Prior authorization required for listed supportive care drugs when administered in outpatient setting for cancer diagnosis
ScopePrior authorization is required for colony-stimulating factor drugs, erythropoiesis-stimulating agents, and bone-modifying agents when administered in an outpatient setting for a cancer diagnosis.
Examples of required J/Q codes
How Providers Must Submit 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) or by phone. Prior authorization is not required for emergency or urgent 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.
Phone: Call 877-842-3210 (general portal guidance also references 888-397-8129 and 866-889-8054 for specific lines)
Prior Authorization
Procedures and surgeries that require prior authorization
Prior authorization is required for many procedure and surgery categories. Providers must obtain authorization before scheduling or performing the procedures listed below (exceptions noted in source text).
Abortion / pregnancy termination — CPTs include 59840, 59841, 59850–59857
Key Terms and Program Definitions
inv-84: Definition of Prior authorization — Process description, emergency/urgent care exclusion.
DefinitionPrior authorization is the process by which providers submit requests (via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone) to UnitedHealthcare for approval before performing certain services.
Submission methodsOnline via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone (877-842-3210).
Emergency/urgent carePrior authorization is not required for emergency or urgent care.
Out-of-network providersOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services except emergent or urgent care.
inv-85: Chemotherapy injectable drugs — J9000-J9999 and examples listed.
Code range
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Ohio 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 877-842-3210.
Orthognathic surgery, rhinoplasty/septoplasty for functional indications, and other specified reconstructive or cosmetic procedures may require prior authorization — consult the Provider Portal for full CPT lists and clinical criteria.
Certain implants and devices (e.g., cochlear implants, stimulators, ventricular assist devices) require prior authorization; some device programs (VAD, transplant/CAR T) have dedicated case management and phone numbers (see Provider Portal and source guidance).
Durable medical equipment (DME): Prior authorization is required regardless of billed amount for many DME categories; some orthotic/prosthetic items require authorization only when retail purchase or cumulative rental exceeds $500. Representative HCPCS/E-codes: E0194, E0277, E0328, E0329, E0457, E0483, K0812, K0830–K0831, K0848–K0851, K0884–K0891, S1040 and others. For incontinence supplies, order through Edgepark Medical Supplies at 844-564-1008.
Site-of-service rules: Prior authorization may be required only when services are rendered in specific sites (for example, prior authorization only for outpatient hospital setting vs ASC). Verify site-of-service requirements per code on the Provider Portal.
Sinuplasty procedures: Prior authorization required for specified CPT codes 31295–31298; site-of-service rules may apply (outpatient hospital vs ASC).
Code- and diagnosis-specific exceptions: Some codes (for example code 38232) may require prior authorization only for an oncology diagnosis; review code-specific notes on the Provider Portal.
Non-oncology useCodes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 and Q5125 also require prior authorization for non-oncology diagnoses.
How to submitSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (see portal instructions in General Information).
inv-37: DME retail purchase/rental PA threshold — Prior authorization required only if retail purchase or cumulative rental cost > $500 for K0886/K0890/K0891
Applies to codesK0886, K0890, K0891
PA thresholdPrior authorization required only if retail purchase or cumulative rental cost is more than $500 for the listed codes.
Exception detailIf retail purchase or cumulative rental cost is $500 or less, prior authorization is not required for these codes.
ScopePrior authorization is required for orthotic and prosthetic items when the retail purchase or cumulative rental cost exceeds $500.
Applicable codesMultiple L-codes are listed throughout the orthotics/prosthetics section (examples include L0170, L0480, L0484, L0634).
Threshold rulePA is only required for orthotics/prosthetics with retail purchase or cumulative rental cost of more than $500; items below this threshold are not subject to PA per this rule.
Bariatric surgery and obesity-related procedures — CPTs include 43644, 43645, 43659, 43770, 43775, 43842
Breast reconstruction (non-mastectomy) — CPTs include 11971, 19316, 19318, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367
Cochlear and other auditory implants — CPTs include 69710, 69714, 69930
Radiation therapy (IGRT/IMRT/proton and related) — CPTs include 77014, 77401, 77402, 77407, 77412, 77331, 77370, 77399, 77470 and proton therapy codes 77520–77525; prior authorization may be diagnosis-limited for certain cancer ICD ranges
Rhinoplasty and septoplasty for functional nasal treatment — CPTs include 30400–30435, 30410, 30420, 30430; prior authorization required
Sleep apnea procedures and related surgeries — listed CPTs include 21685, 41599, 42145 and others
Spinal surgery — numerous CPTs including 22100–22102, 22110, 22112, 22114, 22224, 22510–22515, 22532–22533, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610 and many additional spine codes
Stimulators and neurostimulation (implantable devices and bone growth stimulators) — prior authorization required; CPT/HCPCS and device-specific codes apply (examples include 61863–61868, 61885–61886, 63650, 63655, 63685, 64553, 64555, 64568, 64570, 64590)
Transplants and CAR T-Cell therapy — prior authorization required; contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 (or use the notification number on member ID card) for services including Abecma, Breyanzi, Kymriah, Tecartus and Yescarta
Ventricular assist devices (VAD) — prior authorization required; call the notification number on the member's ID card and fax Optum VAD Case Management at 855-282-8929
Vein procedures and ablation/removal of saphenous trunks/branches — CPTs include 36473, 36475, 36478, 36473, 37700, 37718, 37722, 37765, 37766, 37780 and others
Chemotherapy injectable drugs billed in the J9000–J9999 range require prior authorization.
Q codes and miscellaneous HCPCSChemotherapy drugs with Q-codes and drugs without assigned codes billed under miscellaneous HCPCS also require prior authorization.
Submission instructionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the Provider Portal.
inv-86: Inpatient video EEG (cerebral seizure monitoring) — CPT codes and PA note.
Applicable CPT codes95700, 95711–95713 (inpatient video EEG/cerebral seizure monitoring).
PA requirementPrior authorization is required for inpatient video EEG monitoring when performed inpatient.
Related chemo notePrior authorization is required for inpatient chemotherapy services; outpatient hospital or ambulatory surgical center chemotherapy may not require PA in some settings (see chemotherapy section).
inv-87: Designated vendor for incontinence supplies — Edgepark Medical Supplies.
Designated vendorEdgepark Medical Supplies is the designated vendor for incontinence supplies.
Contact to requestTo request incontinence supplies, call Edgepark Medical Supplies at 844-564-1008.
Benefit conditionIncontinence supplies are a benefit only when provided through Edgepark Medical Supplies.
inv-88: Items of medical equipment requiring prior authorization regardless of billed amount — Durable medical equipment (DME).
Item categoryDurable medical equipment (DME)
PA rulePrior authorization is required for DME regardless of billed amount (general rule).
Exceptions/thresholdsCertain DME codes (e.g., K0886, K0890, K0891) have a $500 retail purchase/cumulative rental threshold for PA — see DME threshold guidance.
inv-89: Prior authorization/notification program — Genetic test notification requirement (BRCA) summary.
Program descriptionNotification/prior authorization is required for specified genetic and molecular tests (including BRCA) before DNA sequencing is performed.
Ordering provider responsibilityThe ordering care provider must notify the laboratory conducting the test; the laboratory will notify the payer as part of the process.
Example CPT codesExamples include 81522, 81546, 81595, 81162 and other BRCA-related codes listed in the genetic testing section.
inv-90: UnitedHealthcare Provider Portal prior authorization tool — Prior Authorization and Notification tool reference.
Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal.
How to accessSign in at UHCprovider.com with One Healthcare ID, select the Prior Authorization and Notification tile on the Provider Portal dashboard.
Submission methodsUse the Provider Portal tool for online submissions; phone support is available (see phone contact entries).
inv-91: OptumRx prior notification — OptumRx prior notifications phone number for certain drugs.
OptumRx notification for SolirisObtain prior notification for Soliris through OptumRx prior notifications services at 800-310-6826.
ContextThis pathway applies to specified drugs noted in the injectable medications section (e.g., Soliris).
Portal submission noteOther prior authorizations for injectable medications should be submitted via the UnitedHealthcare Provider Portal Prior Authorization tool as directed.
inv-92: Diagnosis-limited prior authorization (radiation therapy) — Prior auth only with specified diagnosis code ranges.
ConditionRadiation therapy prior authorization is diagnosis-limited in some cases.
Diagnosis rangesPrior auth required only when obtained with diagnosis codes in the ranges: C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A, D05.00–D05.92.
ApplicabilityApplies to certain standard radiation therapy codes as noted in the radiation therapy section; special/associated services also addressed in that section.
inv-93: Prior authorization submission methods — Portal and phone (866-889-8054).
Portal submissionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).
Phone submissionPhone support numbers noted include 877-842-3210 (general) and 866-889-8054 (radiology/Cardiology/Oncology/Radiation Therapy routing).
AlternateFor certain Commercial product routing within the portal, selecting 'Radiology, Cardiology, Oncology, and Radiation Therapy' may redirect to another website as indicated in the portal instructions.
inv-94: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal — Tool name reference.
Tool titlePrior Authorization and Notification tool (on UnitedHealthcare Provider Portal).
Access instructionsGo to UHCprovider.com, click the Provider Portal button, then select the Prior Authorization and Notification tile on the dashboard.
Phone alternativeIf unable to use the portal, call 866-889-8054 for assistance with prior authorization submissions for specified services.
inv-95: Site of service (SOS) - outpatient hospital — Definition and implication for PA.
DefinitionSite of service (SOS) - outpatient hospital: PA is required when requesting service in an outpatient hospital setting.
ImplicationPrior authorization may also be required if performed at a participating Ambulatory Surgery Center (ASC) depending on the procedure code; site-specific rules apply.
Applicability noteCheck procedure-level PA rules and site-of-service guidance for required PA when scheduling services in outpatient hospital or ASC settings.
inv-96: Transplant prior authorization contact — UnitedHealthcare Community and State Transplant Case Management contact.
ContactUnitedHealthcare Community and State Transplant Case Management team: call 888-936-7246 or use the notification number on the member's ID card.
ScopeApplies to transplant and CAR T-Cell therapy services (listed examples include Abecma, Breyanzi, Kymriah, Tecartus, Yescarta).
SubmissionProviders should call the transplant case management team for authorization instructions per the transplant section.
inv-97: Optum Transplant routing — Optum Transplant is the authorization routing channel for specified gene therapies.
Codes/referenceThese therapies are noted in the gene therapy prior authorization routing guidance and will be routed to Optum Transplant for authorization processing.
Provider actionFollow the Optum Transplant routing instructions when requesting prior authorization for the listed gene therapies.
inv-98: Ventricular assist device (VAD) — Definition of VAD.
DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.
PA requirementVADs require prior authorization.
Contact instructionsProviders should call the notification number on the back of the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.