CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Lists prior authorization submission methods and specific prior authorization requirements for participating Preferred Care Network and Preferred Care Partners of Florida health care professionals for inpatient and outpatient services effective March 1, 2025; affects providers serving members in the listed Florida networks and plans.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Policy CodePolicy N/A

Change TypeOperational update (no material coverage changes)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by calling the listed phone numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-03-01Policy effective

2Submission paths

Some PAs removedCardiology note

ManySpecialty services flagged

Part 3 of 8

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Coverage and Authorization Criteria

Extracted coverage criteria (partial)

Service-specific prior authorization requirements and notable exceptions or notes included in the document excerpt:

Prior authorization is not required for emergency or urgent care.

If a member's ID card states 'Referral Required', a referral from the member's primary care provider and prior authorization may be required for certain services; refer to the 2024 UnitedHealthcare Care Provider Administrative Guide or call the number on the member's ID card.

Behavioral health services: many benefit plans only provide coverage through a designated vendor; for specific CPT/HCPCS codes requiring authorization, call the number on the member's health plan ID card.

Bone growth stimulators (electronic stimulation or ultrasound to heal fractures) — prior authorization required (CPT 20974, 20975).

Breast reconstruction (non-mastectomy) — prior authorization required; diagnosis- and code-specific exceptions are listed elsewhere in the document (see ICD/CPT listings).

Cancer supportive care (outpatient injectable agents) — prior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis; certain J/Q codes also require prior authorization for non-oncology diagnoses (examples: J1442, J1447, Q5108, Q5110, Q5122).

Cardiology/cardiovascular procedures and services — mixed directives in the document: multiple 170.xx and 372xx codes are enumerated; some lines state 'Prior authorization no longer required' while other entries list codes requiring prior authorization. Follow plan- and code-specific guidance (see cardiology code listings).

Cardiology services (partial)

Partial criteria and stance for cardiology-related codes and services as presented in the document segments.

Cardiology authorization summary

Some cardiology entries list specific CPT/HCPCS codes (examples: 170.233, 170.234, 170.239, 170.241, 170.242, 170.243, 37224, 37228).
At multiple points the document states 'Prior authorization no longer required' for cardiology services; other cardiology lines continue to list codes where prior authorization is indicated. Providers must follow plan-specific guidance for each code/member plan.

When diagnosis-specific notes are present (example diagnosis codes E08.52, E09.52, E10.52, E11.52, E13.52), follow the documented linkage of diagnosis to authorization requirement in the cardiology entries.

Code listing without criteria

Code listings only; no accompanying criteria included in this fragment.

Document fragment contains repeated CPT/HCPCS code listings (examples: 170.239, 170.241, 170.242 and multiple 170.xx series entries) presented without detailed criteria in this excerpt; use the code lists for reference and consult full policy for criteria.

Prior authorization / notification criteria (excerpt)

Services and items that require prior authorization or notification include but are not limited to:

Injectable chemotherapy and specialty injectables: chemotherapy injectable drugs (J9000-J9999) and certain agents (e.g., Leucovorin J0640, Levoleucovorin J0641/J0642) require notification; prior authorization requests for injectable chemotherapy should be submitted via the Provider Portal or by calling 888-397-8129.

Durable medical equipment (DME): all DME requests must be directed to a health plan contracted vendor; call the number on the member's health plan ID card for vendor routing.

End-stage renal disease (ESRD) dialysis services: advance notification required for outpatient dialysis and when a member is referred to an out-of-network dialysis provider; to enroll or refer a Medicare member to the Kidney Resource Service call 866-561-7518. Advance notification is not required when a Medicare member travels outside the service area.

Gender dysphoria treatment: prior authorization required for listed CPT/HCPCS codes; certain procedures require notification or prior authorization when submitted with diagnosis codes F64.* or related codes — follow the enumerated CPT/HCPCS listings in the document.

Authorization and code-list criteria (excerpt)

Requirements and examples in this section

Prior authorization and admission notification: prior authorization and notification of admission date are required for post-acute inpatient services provided by acute care hospitals, acute inpatient rehabilitation, critical access hospitals, skilled nursing facilities, and long-term acute care hospitals. Certain UnitedHealthcare plans are excluded from the skilled nursing facility prior authorization requirement (UnitedHealthcare Assisted Living Plans and UnitedHealthcare Nursing Home plan).

How to submit prior authorization requests: use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (uhcprovider.com) selecting Prior submission and Specialty Pharmacy, or call 888-397-8129. naviHealth manages prior authorization for in-scope membership (Phone: 855-851-1127; Fax: 844-244-9482).

Code and drug listings: the section includes extensive HCPCS/CPT code lists for injectable medications, VEGF inhibitors, therapeutic radiopharmaceuticals, and unclassified/temporary codes (examples include J0177–J0179 series, J3399, A9513, J3490). These entries indicate which drugs/procedures are subject to notification or prior authorization per the policy lists.

Prior authorization coverage criteria (summary)

Services and items in the following categories require prior authorization per the plan and may have additional vendor routing:

Orthotics/Prosthetics: prior authorization required for orthotics when retail purchase or cumulative rental cost exceeds $1,000.

Out-of-network referrals: prior authorization required when a network provider recommends an out-of-network provider and the member's plan does not include out-of-network benefits; prior authorization may be used to request in-network cost sharing when no in-network provider is available.

Proton beam therapy: prior authorization required for proton beam therapy CPT codes 77520, 77522, 77523, and 77525. Note the section contains mixed directives for radiation therapy where some radiation therapy entries state 'prior authorization no longer required' for certain codes — follow code-specific guidance.

Stimulator and neurostimulator implantation: prior authorization required for stimulators and implantation of neurostimulator devices (examples: CPT/HCPCS 61850, 61863, 61868, 61885, 63655, 63685, 64590, L8682); all device requests should be directed to a health plan contracted vendor (call number on member's ID card).

Authorization criteria summary

Authorization and case management requirements for listed services and codes:

Neurostimulator implantation and device requests: prior authorization required; all device requests should be directed to a health plan contracted vendor (contact number on the member's health plan ID card).

Organ/tissue transplant and transplant-related services: requests for transplant or transplant-related services prior to pre-treatment or evaluation require prior authorization and referral to the Optum Transplant Case Management team; call Optum Transplant Case Management at 888-936-7246 or follow the notification number on the member's ID card.

Code 38232 (bone marrow harvest): prior authorization is required only when billed with an oncology diagnosis — otherwise follow standard authorization rules.

Vein procedures: prior authorization required (examples include CPT 37243 and 37799 listed).

Ventricular assist devices (VAD): providers must contact the Optum VAD Case Management team for notification and authorization instructions; call 888-936-7246 or see the notification number on the member's health plan ID card.

CPT / HCPCS / ICD-10 Codes

Cardiovascular/endovascular CPT CodesCPTCovered

37220	Endovascular procedure code listed with prior authorization note (asterisked in doc)
37221	Endovascular procedure code listed
37224	Endovascular procedure code listed with prior authorization note (asterisked)
37225	Endovascular procedure code listed with prior authorization note (asterisked)
37226	Endovascular procedure code listed with prior authorization note (asterisked)
37227	Endovascular procedure code listed with prior authorization note (asterisked)
37228	Endovascular procedure code listed with prior authorization note (asterisked)
37229	Endovascular procedure code listed with prior authorization note (asterisked)
37230	Endovascular procedure code listed with prior authorization note (asterisked)
37231	Endovascular procedure code listed

Orthopedic and breast reconstruction CPT CodesCPTCovered

20974	Bone growth stimulator
20975	Bone growth stimulator
19316	Breast reconstruction (non-mastectomy)
19318	Breast reconstruction (non-mastectomy)
19325	Breast reconstruction (non-mastectomy)

Cancer supportive care J-codesHCPCSCovered

J1454

Akynzeo (palonosetron/fosnetupitant) - injectable supportive care

ICD-10 codes for breast reconstruction exceptionsICD-10

C50.011	Breast cancer diagnosis code listed as exception to prior authorization requirement following mastectomy (example)
C50.919	Breast cancer diagnosis code listed
Z90.11	History of breast surgery code referenced

Other procedure codes (CPT/HCPCS)CPT

170.233	Procedure code referenced (document lists multiple related codes)
170.239	Procedure code referenced
170.241	Procedure code referenced
170.242	Procedure code referenced
170.243	Procedure code referenced

Frequently referenced CPT/HCPCS codes (partial)CPT | HCPCS

170.239	Listed CPT/HCPCS code referenced across chunks
170.241	Listed CPT/HCPCS code referenced across chunks
170.242	Listed CPT/HCPCS code referenced across chunks
170.243	Listed CPT/HCPCS code referenced across chunks

Additional cardiology CPT/HCPCS codes (partial)CPT | HCPCS

170.244	Example CPT/HCPCS code entries listed in document (full list in provider_actions)
170.245	Cardiovascular code listed in document
170.248	Cardiovascular code listed in document
170.249	Cardiovascular code listed in document

ICD-10: Diabetes with skin ulceration codesICD-10

E08.52	Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene (as listed)
E09.52	Drug or chemical induced diabetes mellitus with peripheral angiopathy with gangrene (as listed)
E10.52	Type 1 diabetes mellitus with peripheral angiopathy with gangrene (as listed)
E11.52	Type 2 diabetes mellitus with peripheral angiopathy with gangrene (as listed)
E13.52	Other specified diabetes mellitus with peripheral angiopathy with gangrene (as listed)

CPT/HCPCS procedure codes (fragmented list)HCPCS

170.239	Procedure code referenced
170.241	Procedure code referenced
170.242	Procedure code referenced
170.233	Procedure code referenced
170.234	Procedure code referenced

ICD-10 diagnosis codes referencedICD-10Covered

E08.52	Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene (as listed)
E09.52	Drug or chemical induced diabetes mellitus with peripheral angiopathy with gangrene (as listed)
E10.52	Type 1 diabetes mellitus with peripheral angiopathy with gangrene (as listed)
E11.52	Type 2 diabetes mellitus with peripheral angiopathy with gangrene (as listed)

Representative CPT/HCPCS codeCPT

170.244

Example CPT/HCPCS code entries listed in document (representative)

ICD-10 diagnosis codes (device/osteomyelitis)ICD-10

M86.*	Various osteomyelitis ICD-10 codes listed throughout M86 series
T82.*	Device related complication ICD-10 codes referenced

HCPCS/CPT/J-codes for injectable drugs and biologicsHCPCSCovered

J9000-J9999	Chemotherapy injectable drug range
J1442	Colony-stimulating factor example (listed)
J3247	Cosentyx IV

Procedure CPT ranges requiring prior authorization/notificationCPTCovered

21235-21299	Multiple reconstructive procedure CPT codes listed
67900-67966	Ophthalmic/related procedure CPT codes listed

Selected injectable HCPCS codesHCPCS

J1442	Colony-stimulating factor
J1745	Infliximab (example listed)
J7320	Hyaluronic acid polymer (various unit mappings listed)

Radiopharmaceutical and unclassified drug codesHCPCS

A9513	Therapeutic radiopharmaceutical
J3490	Unclassified drug code

Selected CPT codes referencedCPT

21145	Maxillofacial procedure code listed in section
21146	Maxillofacial procedure code listed in section
21147	Maxillofacial procedure code listed in section
22100	Orthopedic spine/joint surgery code listed (prior authorization required)
22532	Spine surgery code referenced

Proton beam therapy CPT codesCPTExperimental

77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy

Selected CPT/HCPCS codes referencedmixed

E0747	Stimulator supply (example)
E0760	Implantable device supply (example)
61850	Neurostimulator implantation procedure
38232	Bone marrow harvest (authorization only for oncology diagnosis)
J3393	Cellular/gene therapy HCPCS example

CPT/HCPCS codes availability

ScopeDocument enumerates numerous CPT and HCPCS procedure and drug codes (including J‑codes, A‑codes, G‑codes, CPT ranges) that require prior authorization or notification for Preferred Care Network/Preferred Care Partners.

Representative code examplesIncludes chemotherapy injectable range J9000-J9999, therapeutic radiopharmaceuticals A9513/A9590, VEGF inhibitor J0177/J2777, and selected procedure codes (see provider portal lists).

How to obtain authorization for listed codes

Submission, Notifications, and Vendor Contacts

Prior Authorization

Online submission instructions — Prior Authorization and Notification tool on UnitedHealthcare Provider Portal

Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. To get started, go to UHCprovider.com and click Sign In at the top-right corner to log in using your One Healthcare ID and password. Then select the Prior Authorization and Notification tab on your dashboard. If you don't have a One Healthcare ID, visit uhcprovider.com to register.

Submit prior authorization requests and notifications via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.
After signing in, select the Prior Authorization and Notification tab and follow the prompts to submit specialty or procedure-specific requests.

Prior Authorization

Phone submission and referral note

Phone submission options are available for practitioners and facilities. Use the appropriate number below based on the network:

Preferred Care Network: Call 866-273-9444
Preferred Care Partners: Call 800-995-0480

Definitions and Operational Terms

Referral Required

DefinitionReferral Required — when a member's health plan ID card indicates 'Referral Required', certain services may require a referral from the member's primary care provider and prior authorization obtained by the treating physician.

When it appliesApplies to plans listed in the administrative guide and as indicated on the member's ID card.

Provider actionVerify member ID card for 'Referral Required' and follow referral and prior authorization processes as described in the UnitedHealthcare Care Provider Administrative Guide.

Prior authorization no longer required

Operational noteSome cardiology services are explicitly noted as 'Prior authorization no longer required' in the cardiology section; however other cardiology codes in the document still list authorization requirements — follow the specific code-level guidance.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida

Policy CodePolicy N/A

Change TypeOperational update (no material coverage changes)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by calling the listed phone numbers.

SourceLink

On This Page

Cosmetic and reconstructive procedures: prior authorization or notification required for many reconstructive/cosmetic CPT codes; reconstructive procedures that restore physiologic function are distinguished from cosmetic-only procedures in the full policy.

Procedure/diagnosis linkages: the document lists numerous ICD-10 codes (notably M86.* osteomyelitis series and device complication codes T82.* and others) tied to procedural prior authorization requirements; consult the linked code lists for specific mappings.

VEGF inhibitors and selected specialty drugs: multiple VEGF inhibitor J-codes and other specialty drug J/Q codes are listed (examples J0177–J0179, J2777–J2779, Q5124, Q5128, J3032, J3401); prior authorization submission instructions are provided in the document (Provider Portal or phone).

Cellular and gene therapy services: these services and related unclassified codes are listed and require follow-up per the transplant/cellular therapy prior authorization processes; consult the document for listed T/C/J codes and vendor contact instructions.

Submit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com (Provider Portal) or call 888-397-8129; some vendor-managed categories route to naviHealth or specialty vendors.

Document guidanceCertain codes or code groups have mixed directives (some codes ‘prior authorization no longer required’ while others in same family still require authorization) — follow the specific code entries and plan routing.

Vendor routing notenaviHealth manages prior authorization for certain in-scope membership (phone: 855-851-1127; Fax: 844-244-9482) and specialty device/drug requests may be directed to contracted vendors.

Orthotics / prosthetics prior authorization threshold

ThresholdPrior authorization required when orthotics are retail purchased or cumulative rental cost exceeds $1,000.

Applies toOrthotics and prosthetics items covered under Preferred Care Network/Preferred Care Partners guidance.

How to requestSubmit prior authorization per standard Provider Portal or vendor-specific instructions; contact number on member ID for contracted vendor.

RationaleThreshold establishes when high-cost purchases or cumulative rentals require advance review to confirm coverage and appropriate sourcing.

Prior authorization is not required for emergency or urgent care.

Plans that require referrals: If a member's ID card indicates “Referral Required,” certain services may require a referral from the member's primary care provider and prior authorization obtained by the treating physician — follow plan-specific referral guidance in the UnitedHealthcare Care Provider Administrative Guide.

Prior Authorization

WellMed submission option — certain WellMed groups should use WellMed provider portal or phone

WellMed group-specific prior authorization submission options.

Certain WellMed groups should submit prior authorization requests using the WellMed provider portal at eprg.wellmed.net or by calling 877-299-7213 (8 a.m.–5 p.m. ET, Monday–Friday).
Affected WellMed groups include MedicareMax (HMO) Groups: 98151, 98152; MedicareMax Plus (HMO D‑SNP) Groups: 98153, 98154, 98155; MedicareMax Chronic (HMO C‑SNP) Group: 90215.

Prior Authorization

Cardiology services with diagnosis-specific notes (partial)

Cardiology services: mixed prior authorization status depending on service and diagnosis. Some cardiology procedures no longer require prior authorization while others remain subject to prior authorization or diagnosis-specific rules.

Prior authorization no longer required for certain cardiology services (see plan/portal for details).
Some cardiology CPT/HCPCS codes remain subject to prior authorization for Preferred Care Partners — refer to the code groups and diagnosis-specific rules in the code listings below.
Certain cardiology services require prior authorization only when submitted with specific diagnosis codes (for example diabetes-related codes such as E08.52, E09.52, E10.52, E11.52, E13.52 noted in the source).

Billing Rule

CPT/HCPCS code listings and mixed code groups (consolidated)

Large groups of CPT/HCPCS and diagnosis codes referenced in this section require mapping to prior authorization rules. The lists below consolidate codes and diagnosis references that drive prior authorization or notification requirements — providers must reference the online portal or the plan-specific code groups when submitting requests.

Numerous CPT/HCPCS procedure groups are listed for Preferred Care Partners (examples include code ranges and specific codes beginning with 170.*, 174.*, 175.*, 37224, 37243, 37799 and many 170-series groupings).
Mixed lists include CPT/HCPCS and ICD‑10 diagnosis codes (examples from source: T82.818A, T82.868A, S81.801A, S91.301A, M86.* series and others).
Cardiology/CV code group examples from the source include many 170.xxx entries (170.233–170.569 series and beyond) and other procedure codes; consult the portal code lookup for exact mappings when submitting.
Radiation, proton beam and stereotactic radiosurgery CPT/HCPCS codes referenced include 77520, 77522, 77523, 77525, 77371–77373, 77387 and associated G‑codes (G6001, G6002, G6017).

Prior Authorization

Prior authorization submission channels and how to obtain prior authorization / vendor contact

How to obtain prior authorization and vendor contacts — consolidated submission channels and vendor routing instructions.

Primary submission channel: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at uhcprovider.com. After signing in, select the Prior Authorization and Notification tab to begin a submission.
Phone alternative for many injectable drug or specialty pharmacy prior authorizations: call 888-397-8129.
Specialty prior authorization vendors noted in source: naviHealth manages prior authorization for in‑scope membership (Phone: 855-851-1127; Fax: 844-244-9482).
For transplant and certain device programs, contact the Optum Transplant Case Management team at 888-936-7246 (or use the notification number on the back of the member's ID card).
Durable medical equipment (DME) requests: direct all DME requests to the health plan contracted vendor — call the number on the member's health plan ID card.
Ventricular assist device (VAD) management: contact the Optum VAD Case Management team at 888-936-7246 or the notification number on the member's ID card.

Prior Authorization

Admission notification and prior authorization requirement — post‑acute and ESRD dialysis notifications

Admission notification and prior authorization requirement for inpatient and post‑acute services.

Notification required: Advance notification is required when a member is referred to an out‑of‑network care provider for dialysis services; using an in‑network dialysis center can reduce member cost‑share.
Prior authorization and notification of admission date are required for post‑acute inpatient services, including: acute care hospitals, acute inpatient rehabilitation, critical access hospitals, skilled nursing facilities (SNF) and long‑term acute care hospitals (LTAC).
Note: Some UnitedHealthcare plans are excluded from the SNF prior authorization requirement (e.g., certain UnitedHealthcare Assisted Living or Nursing Home plans) — check plan-specific administrative guides.

Prior Authorization

Transplant-related services and 38232 exception

Transplant-related services require prior authorization before pre‑treatment or evaluation. Code 38232 is an exception: it requires prior authorization only when submitted with an oncology diagnosis.

Organ or tissue transplants and transplant‑related services (including evaluation, bone marrow harvest 38240–38242, transplant evaluations such as 99205, and organ‑specific procedure codes such as heart 33940/33944/33945, heart–lung 33930, intestine 33935, liver codes 47135 and related codes) require prior authorization before pre‑treatment or evaluation.
For cellular and gene therapy services (examples: idecabtagene, lisocabtagene, ciltacabtagene, tisagenlecleucel, etc.), contact the Optum Transplant Case Management team at 888-936-7246 or the notification number on the member's ID card for routing and authorization.
Code 38232 will only require prior authorization when billed with an oncology diagnosis (per source).
Unclassified/temporary HCPCS or J‑codes used for transplant‑related therapies (for example C9399, J3490, J3590, J9999 and other listed Q‑codes) follow the transplant/cellular therapy prior authorization routing — submit via portal or contact Optum Transplant Case Management.

Do not assume all cardiology procedures are exempt; check the code entries and plan routing before proceeding.

Provider actionUse Provider Portal or contact prior authorization phone numbers to confirm authorization status for specific cardiology CPT/HCPCS codes.

Preferred Care Partners

TermPreferred Care Partners — network designation referenced throughout the document for which specific prior authorization code lists and requirements are provided.

ContextCode lists and service categories in the document are organized by Preferred Care Partners (and Preferred Care Network) routing and vendor instructions.

Provider actionFollow the Preferred Care Partners–specific code listings and submission pathways when treating members in those plan groups.

Preferred Care Partners

TermPreferred Care Partners — used repeatedly as the plan group for which the authorization tables and code entries apply.

Use in documentPreferred Care Partners sections include CPT/HCPCS and ICD-10 linkages and additional information for coverage decisions.

Provider actionIf member is in a Preferred Care Partners plan, reference the Preferred Care Partners code group entries and submission instructions in this guidance.

notification

DefinitionNotification — an advance notice requirement for certain services (for example, chemotherapy injectable drugs require notification and/or prior authorization as specified).

ExamplesChemotherapy injectable drugs (J9000-J9999), Leucovorin (J0640), Levoleucovorin (J0641, J0642) require notification; submit via Provider Portal or call specified number.

Provider actionSubmit notification or prior authorization per instructions (Provider Portal at UHCprovider.com or call 888-397-8129) for listed drug/therapy codes.

advance notification (ESRD)

Definition & scopeAdvance notification (ESRD) — required for end-stage renal disease dialysis services, including outpatient dialysis; enroll or refer Medicare members to Kidney Resource Service (866-561-7518).

ExceptionsAdvance notification is not required when a Medicare member travels outside the service area.

Provider actionWhen referring ESRD members to dialysis services or out-of-network dialysis providers, complete advance notification per the guidance and call the Kidney Resource Service as needed.

Prior authorization and notification

DefinitionPrior authorization and notification — requirement that providers obtain approval or notify UnitedHealthcare before certain inpatient and post-acute admissions (acute hospitals, AIR, critical access hospitals, SNF, LTAC).

Excluded plansSome plans (UnitedHealthcare Assisted Living Plans and UnitedHealthcare Nursing Home plan) are excluded from SNF prior authorization requirement; check plan details.

Provider actionUse the Provider Portal or contact the prior authorization phone number to submit required notifications/authorizations for applicable admissions.

Out-of-network services

DefinitionOut-of-network services — services provided by a facility, physician, or care provider that is not contracted with Preferred Care Network/Preferred Care Partners; a network recommendation to an out-of-network provider may require prior authorization.

When authorization is requiredPrior authorization required when a network provider directs a member to an out-of-network provider and the member's benefit plan does not include out-of-network benefits, or to request in‑network cost sharing when no in‑network providers are available.

Provider actionSubmit prior authorization to request coverage or in‑network cost sharing adjustments when referring to out‑of‑network providers; verify member benefits first.

Orthotics requiring prior authorization

ThresholdOrthotics requiring prior authorization — retail purchase or cumulative rental cost greater than $1,000 triggers prior authorization requirement.

ScopeApplies to orthotics items listed under Preferred Care Network/Preferred Care Partners guidance.

Provider actionFor orthotics exceeding the threshold, submit prior authorization via Provider Portal or contact the contracted vendor per member ID instructions.

VAD definition

DefinitionVentricular assist device (VAD) — a mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

Provider instructionContact the Optum VAD Case Management team at 888-936-7246 or use the notification number on the back of the member's ID card for notification and authorization instructions.

Associated codesVAD-related CPT/HCPCS and transplant service codes are listed in the document; follow code-level authorization rules and case management routing.