CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Arizona Complete Health Medicaid

Lists prior authorization requirements and instructions for health care professionals participating with UnitedHealthcare Community Plan of Arizona Complete Care (ACC) Medicaid; includes codes, specialties, and submission methods.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Complete Health Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJuly 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or call 800-445-1638.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

July 1, 2024effective date

Online & Phonerequest methods

Manycode lists

Chemotherapy, CGM, ImplantsPA required (examples)

PA/notification requiredinpatient admissions

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Coverage rules, exceptions, and authorization criteria

Coverage rules and exceptions

General coverage rules and notable exceptions:

Services must be covered benefits as defined by AHCCCS to be eligible for prior authorization.

Only medically necessary, cost-effective, federally- and state-reimbursable services are covered per AHCCCS.

All rendering health care professionals, facilities and vendors must be actively registered with AHCCCS.

Services provided by non-network and out-of-state providers require prior authorization and supporting documentation.

Services delivered inside MSIC to CRS-designated members do not require prior authorization.

Allergy immunotherapy exceptions

For members younger than 21: allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary.
For members 21 and older: allergy immunotherapy (including SCIT, SLIT or other routes) is not a covered benefit except where prior authorization is required for sustained anaphylactic or life‑threatening reactions as described in policy.

Experimental and investigational services are not covered benefits.

Authorization and coverage notes

Coverage/authorization notes captured in the document:

Injectable chemotherapy drugs (J9000–J9999; J0640, J0641, J0642, J1950) require prior authorization for outpatient administration; submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Continuous glucose monitors require prior authorization when used with a Type 2 diabetes diagnosis (specific HCPCS/E‑codes listed).

EEG/seizure monitoring notes

Cerebral seizure monitoring codes (e.g., 95700–95726 series) may require prior authorization for monitoring services.
Inpatient video EEG: prior authorization is not required for outpatient hospital or ambulatory surgical center (ASC) settings.

Auditory/cochlear implants have prior authorization requirements with age-specific rules for members <21 versus ≥21.

Prior authorization and documentation criteria

Prior authorization and documentation requirements by service type:

DME authorization: Prior authorization is required for listed DME/HCPCS codes and for items with a retail purchase or cumulative rental cost greater than $500; Preferred Homecare is the contracted vendor for many DME items (800-636-2123).

Enteral/parenteral nutrition: Clinical documentation and a Certificate of Medical Necessity (CMN) must accompany requests for enteral/oral supplements and establish medical necessity; for members younger than 21 review AHCCCS Medical Policy (AMPM) guidance.

Experimental/investigational services: Prior authorization is required for services considered experimental or investigational; see referenced codes and AMPM guidance.

Genetic testing not covered by LabCorp requires prior authorization; providers should contact LabCorp to determine prior authorization requirements and submit required documentation.

Partial authorization and coverage criteria

Coverage and authorization notes (partial):

Hearing evaluations (CPT 92590–92593) for members younger than 21: prior authorization not required for specified evaluation codes.

Hearing aids for members 21 and older (e.g., V5014, V5030, V5040, V5050) require prior authorization.

Home health care services require prior authorization for listed codes (e.g., G0299, G0300, S9123, S9124).

Infusion in‑home services and injectable medications not covered by Optum Infusion require prior authorization; to request services or medications contact Optum Infusion at 888-705-4470.

Prior authorization criteria (document segment)

Prior authorization or notification required for the following categories and codes:

Inpatient admissions / post-acute: Prior authorization and notification of the admission date are required for acute care hospitals, acute inpatient rehabilitation, long‑term acute care hospitals, and skilled nursing facilities.

Laboratory services require prior authorization—contact LabCorp at 800-788-9743 for prior authorization requirements.

Orthotics and prosthetics: Prior authorization is required for listed orthotics and prosthetics L‑codes; coverage applies when the orthotic is medically necessary, may be preferred treatment or less expensive than alternatives, and some items trigger prior authorization when retail cost exceeds $500 or per age‑specific rules.

Orthotics and prosthetics

Orthotics and prosthetics coverage notes and HCPCS codes:

Orthotic coverage: the orthotic must be medically necessary and ordered by a physician or primary care provider.

Coverage considerations

An orthotic may be covered if it is less expensive than other treatment options or surgical procedures for the same diagnosed condition.
Medicare guidelines and specific L‑codes are referenced; prior authorization is required for the listed L‑codes.

Providers should follow AHCCCS orthotics coverage conditions and submit required documentation to support medical necessity.

Outpatient therapy (OT/PT/SLP) coverage and prior authorization

Outpatient therapy coverage and prior authorization rules differentiated by member age:

Occupational and physical therapy are covered when medically necessary; no annual benefit limits apply, but requests are reviewed for medical necessity.

Members younger than 21: Prior authorization is required after the initial evaluation and before the initial therapy visit and is required for all ongoing therapy visits; requests are reviewed for medical necessity.

Members 21 and older

For members 21 and older: some document sections state prior authorization is not required for occupational and physical therapy (follow age‑specific rules in the policy).
However, prior authorization is required after the initial evaluation and before the initial therapy visit and for ongoing visits when indicated by code or site‑of‑service rules—follow the specific instructions in the therapy prior authorization workflow.

Speech therapy coverage criteria

Speech therapy coverage rules by age group and special populations

Members <21: Speech therapy services are covered when medically necessary with no annual benefit limits; requests are reviewed for medical necessity.

Members 21+: Outpatient speech therapy may not be a covered benefit in some contexts for members 21 and older; prior authorization is required after the initial evaluation and before the initial therapy visit and for ongoing therapy visits. QMB exceptions apply (speech therapy covered when medically necessary).

Prior authorization criteria for therapies, imaging, and procedures

Prior authorization required for many outpatient therapies and listed procedures

Occupational and physical therapy: prior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits when indicated by policy and code lists.

Advanced outpatient imaging (certain CT, MRI, MRA, PET and select nuclear medicine/nuclear cardiology) requires prior authorization; submit via the Provider Portal Prior Authorization and Notification tool or call 866-889-8054.

Selected surgical and specialty procedures (e.g., prostate procedures, proton beam therapy, sinuplasty and other listed CPTs) require prior authorization per the code lists provided in the policy.

Pharmacy PA criteria

Pharmacy prior authorization requirements

Prior authorization is required for listed pharmacy drugs; service requests must include applicable 'J' codes and NDC codes.

Contact UnitedHealthcare Pharmacy Prior Authorization Service: phone 800-310-6826, fax 866-940-7328; specialty pharmacy prior authorization fax 866-940-7328.

Examples

Certain hemophilia factor and biotech drugs are included on the PA list (examples: Aldurazyme, Cerezyme, Kalydeco, Lumizyme, Zolgensma).
Physician-administered drugs and J‑codes referenced in the policy require PA as listed (see code lists in the document).

Coverage notes and prior authorization

Prior authorization requirements and site-of-service notes present in this segment

Prior authorization is required for specified surgical groups including sleep apnea procedures (e.g., 21685, 41599, 42145) and other listed surgeries.

Skilled nursing facility services require prior authorization.

Site-of-service (SOS) notes: prior authorization is only required when requesting service in an outpatient hospital setting; procedures performed at a participating ambulatory surgery center (ASC) may not require prior authorization — follow the SOS guidance for specific CPTs.

Transplant/CAR T prior auth criteria

Requirements for transplant and CAR T-cell services:

Clinical documentation must accompany transplant requests to establish medical necessity; prior authorization is required for listed transplant codes.

For CAR T-cell products (e.g., Carvykti, Kymriah, Lyfgenia, Tecartus, Yescarta) call the UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 or use the notification number on the member's ID card for submission and coordination.

Sterilization criteria

Sterilization and consent requirements:

Prior authorization is required for listed sterilization procedure codes.

Any member requesting sterilization must sign an appropriate Consent for Sterilization form; see AMPM Chapter 400 Section 420 Section E for details and the consent form location.

VAD and transportation criteria

VAD and transportation requirements:

Vein procedures and Ventricular Assist Device (VAD) related codes require prior authorization as listed in the policy.

Non‑emergent transportation (taxi or stretcher van) requires prior authorization; to schedule call Medical Transportation Management (MTM) at 888-700-6822.

For VAD notification follow the instructions on the member ID card and fax required VAD case management forms to Optum VAD Case Management as instructed in the policy.

Wound vac criteria

Wound vac:

Wound vacuum therapy code E2402 requires prior authorization.

Relevant CPT, HCPCS, J-, L-, and ICD-10 codes

Augmentative and alternativeCPTCovered

92607	Augmentative and alternative communication
92608	Augmentative and alternative communication
92609	Augmentative and alternative communication
A9901	Augmentative and alternative communication supply

Augmentative and alternativeCPTCovered

92607	Augmentative and alternative communication
92608	Augmentative and alternative communication
92609	Augmentative and alternative communication
A9901	Augmentative and alternative communication supply

Breast reconstructionCPTCovered

19328	Breast reconstruction (non-mastectomy)
19350	Breast reconstruction
19330	Breast reconstruction
19357	Breast reconstruction

Colony-stimulating factors and bone-modifying agentsHCPCSCovered

J1442	Filgrastim (Neupogen) injection
Q5110	Filgrastim-aafi (Nivestym)
J2506	Pegfilgrastim (Neulasta)
J0897	Denosumab (Xgeva)

Cardiovascular and vascular-related CPT/ICD-10 entriesmixedCovered

37220	Endovascular therapy codes (example listed under Cardiovascular)
93580	Cardiac catheterization code listed

Authorization and Notification program ICD identifiersICD-10

I70.635	Authorization and Notification Program identifier (cardiovascular-related entries)
I70.638	Authorization and Notification Program identifier
I70.639	Authorization and Notification Program identifier

Chemotherapy injectable HCPCS/CPT groupHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Lupron Depot

Selected DME/HCPCS and K-codesHCPCS | mixedCovered

E0194	DME HCPCS code listed for prior authorization
E0265	DME HCPCS code listed for prior authorization
E0636	Bone stimulator HCPCS code
E0656	Diabetic supplies HCPCS code
K0005	K-series prosthetic/orthotic code
K0860	K-series orthotic code

Selected CPT procedure codes requiring prior authorizationCPTCovered

29914	Arthroscopy/FAI procedure code
31240	Functional endoscopic sinus surgery code

Selected laboratory and pathology codes (partial)CPT

81460	Molecular pathology / sequencing-related CPT mention
81479	Unlisted molecular pathology procedure (mentioned)
86353	Immunoassay or related code (mentioned)
88245	Cytogenetic analysis (mentioned)

Injectable medication J-codes (partial list)HCPCSCovered

J1413	Injectable medication (Elevidys) — J-code listed
J2508	Injectable medication (Elfabrio)
J3380	Entyvio
J1302	Enjaymo
J7204	Esperoct
J3111	Evenity
J1305	Evkeeza
J0177	Eylea HD
J1951	Fensolvi
J9155	Firmagon

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Injectable medications (examples)HCPCS

J0129	Orencia
J2267	Omvoh
J0222	Onpattro
J1576	Panzyga
J0606	Parsabiv
J1203	Pombiliti
J0897	Prolia
J1301	Radicava
J0896	Reblozyl
Q5125	Releuko

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Additional injectable and radiopharmaceutical codesHCPCS

J3241	Tepezza
J2356	Tezspire
A9513	Therapeutic radiopharmaceuticals
A9590	Therapeutic radiopharmaceuticals
A9606	Therapeutic radiopharmaceuticals
A9607	Therapeutic radiopharmaceuticals
A9699	Therapeutic radiopharmaceuticals

Orthotics / prosthetics L-codes (sample)HCPCS

L2106	HCPCS L-code referenced for orthotics/prosthetics/prior auth
L2108	HCPCS L-code referenced for orthotics/prosthetics/prior auth
L2126	HCPCS L-code referenced
L2350	HCPCS L-code referenced
L2510	HCPCS L-code referenced
L2526	HCPCS L-code referenced
L2627	HCPCS L-code referenced
L2628	HCPCS L-code referenced

Outpatient therapy CPT/HCPCS codesmixedCovered

97012	Therapy modality code
97014	Therapy modality code
97016	Therapy modality code
97113	Occupational therapy eval/re-eval / modality
97530	Therapeutic activities
97124	Physical therapy therapeutic procedure
97140	Manual therapy
97799	Unlisted physical medicine/rehab service
G0281	Supervision of respiratory therapy, example group code listed
G0283	Therapy related code listed

Speech therapy CPTsCPTCovered

92507	Speech therapy CPT mapping
92508	Speech therapy CPT mapping
92526	Speech therapy CPT mapping

Selected procedure CPTs requiring prior authorizationCPTCovered

77520	Proton beam therapy CPT
77522	Proton beam therapy CPT
45378	Colonoscopy CPT
66821	Cataract surgery CPT
64721	Carpal tunnel surgery CPT
30400	Rhinoplasty CPT
31295	Sinuplasty CPT

Example J-codes / physician-administered drugsHCPCSCovered

J1300	Physician administered drug mapping shown
J1303	Physician administered drug mapping shown
J1427	Physician administered drug mapping shown
J3399	Pharmacy/prior auth example J-code

Selected procedure codes by systemCPT

49505	Hernia repair
10121	Integumentary system code listed
20552	Musculoskeletal injection/manipulation code listed

Spinal surgery codesCPT

22100	Spinal surgery codes listed
22514*	Listed in spinal surgery sequence
63075	Laminectomy/laminotomy series

CAR T-cell / temporary / unclassified codesCPT | HCPCS | mixedCovered

0537T	CAR T-cell related temporary code
0538T	CAR T-cell related temporary code
0539T	CAR T-cell related temporary code
0540T	CAR T-cell related temporary code
J9999	Unclassified drug
Q2041	HCPCS code listed
Q2042	HCPCS code listed
Q2053	HCPCS code listed
Q2054	HCPCS code listed
Q2055	HCPCS code listed

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DME prior authorization threshold

ThresholdPrior authorization required for retail purchase or cumulative rental cost greater than $500

Applies toDurable Medical Equipment (DME) and listed HCPCS codes

Vendor referenceSee UnitedHealthcare Community Plan Provider Manual and contracted vendors listings

How providers request authorization and required operational contacts

Prior Authorization

How to request prior authorization

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) with your One Healthcare ID, or call 800-445-1638.

Prior Authorization

Cardiology prior authorization submission

Cardiology prior authorization requests should be submitted via the Provider Portal Prior Authorization and Notification tool or by calling 866-889-8054; see UHCprovider.com/AZcommunityplan for the CPT codes that require prior authorization.

Prior Authorization

Drug prior authorization submission

For colony-stimulating factors and other listed physician-administered drugs submit requests online via the Prior Authorization and Notification tool or call 888-397-8129.

Policy definitions and reference terms

Arizona Health Care Cost Containment System (AHCCCS)

DefinitionArizona Health Care Cost Containment System (AHCCCS): defines covered benefits and reimbursement rules for eligibility of prior authorization

RoleServices must be covered benefits as outlined by AHCCCS to be eligible for prior authorization

Reference guidanceAHCCCS Medical Policy Manual (AMPM) referenced for specific coverage (e.g., EPSDT, enteral nutrition)

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage

DefinitionEarly and Periodic Screening, Diagnostic and Treatment (EPSDT): coverage for members younger than 21 when medically necessary

ExamplesAllergy immunotherapy and testing are covered under EPSDT for members <21 when medically necessary

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Arizona Complete Health Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJuly 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or call 800-445-1638.

SourceLink

On This Page

Prior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits when specified by the policy or code lists.

How to submitSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

Orthotics/prosthetics retail cost

ThresholdPrior authorization required for orthotic/prosthetic items with retail cost of more than $500

Applies toOrthotics and prosthetics L-codes listed in the policy (see L0112, L0462, L0484, L0859, etc.)

Age notesSome orthotic codes include member age-specific notes (e.g., for members younger than 21)

Repair/ReplacementReasonable repairs and serviceability considerations are referenced in code notes

Site of service prior auth

RulePrior authorization is required only when the service is requested in an outpatient hospital setting; not required if performed at a participating ambulatory surgery center (ASC)

Applies toSite of service (SOS) - outpatient procedures and listed CPT codes (e.g., sinuplasty, select surgical CPTs)

ActionWhen requesting services in outpatient hospital setting, include site-of-service information on the prior authorization request

ReferenceSee listed SOS CPT codes (e.g., 29823–29828, 57522, 58558, others) for specific determinations

Prior Authorization

Chemotherapy prior authorization

Injectable chemotherapy drugs (J9000–J9999), leucovorin (J0640), levoleucovorin (J0641, J0642) and Lupron Depot (J1950) require prior authorization; submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors require prior authorization when used with a Type 2 diabetes diagnosis; the policy lists specific HCPCS/E‑codes associated with CGMs.

Prior Authorization

Auditory implant prior authorization

Cochlear and other auditory implants require prior authorization; the document distinguishes requirements for members younger than 21 and members 21 and older and lists applicable CPT/HCPCS codes.

Prior Authorization

Seizure monitoring / EEG prior authorization

Prior authorization is required for specified cerebral seizure monitoring CPT codes; inpatient video EEG prior authorization is not required for outpatient hospital or ambulatory surgical center settings.

Documentation Required

Diabetic supplies vendor information

Diabetic supplies are provided by the local pharmacy; locate contracted vendors and location information at UHCprovider.com/AZcommunityplan.

Prior Authorization

DME and HCPCS prior authorization

Prior authorization is required for the listed DME/HCPCS codes and for items with a retail purchase or cumulative rental cost greater than $500; Preferred Homecare is the contracted vendor for many DME items (800-636-2123).

Documentation Required

Enteral/parenteral nutrition prior authorization and documentation

Clinical documentation and a Certificate of Medical Necessity must accompany requests for enteral/parenteral/oral nutritional supplements; for members younger than 21 review AHCCCS Medical Policy.

Prior Authorization

Experimental/investigational and selected procedure prior authorization

Prior authorization is required for services considered experimental/investigational and for the listed procedure codes; refer to AMPM Chapter 300, Section 320, Policy 320‑B and submit required documentation with requests.

Prior Authorization

Genetic testing prior authorization and codes

Genetic testing not covered by LabCorp requires prior authorization; a range of CPT and biomarker codes are listed and providers should call LabCorp to determine prior authorization requirements.

Prior Authorization

Procedure-specific prior authorization

Prior authorization is required for the listed procedure codes (for example FAI arthroscopy codes and functional endoscopic sinus surgery CPTs); submit requests per the Provider Portal process.

Prior Authorization

Diabetic supplies and glucometer authorization

Diabetic supplies are provided by the local pharmacy; glucometers are available through the medical prior authorization process—locate contracted vendors at UHCprovider.com/AZcommunityplan.

Prior Authorization

Injectable medications / Infusion in-home services

To request injectable medications or in‑home infusion services, call Optum Infusion at 888-705-4470; prior authorization is required for medications and services not covered by Optum Infusion.

Prior Authorization

Incontinence supplies

To request incontinence supplies, call Preferred Homecare; incontinence supplies are a benefit only when provided through Preferred Homecare.

Prior Authorization

Home health care services

Prior authorization is required for the listed home health care service codes (G0299, G0300, S9123, S9124).

Documentation Required

Hearing services / hearing aids

Hearing evaluations for members younger than 21 do not require prior authorization for the listed CPTs, but prior authorization is required for hearing aids for members 21 and older.

Prior Authorization

Inpatient admissions and post-acute services prior authorization

Prior authorization and notification of the admission date are required for acute care hospitals, acute inpatient rehabilitation, long‑term acute care hospitals and skilled nursing facilities.

Prior Authorization

Joint procedures prior authorization

Prior authorization is required for the listed joint and joint replacement procedure codes.

Prior Authorization

Orthotics and prosthetics prior authorization

Orthotics and prosthetics codes listed require prior authorization; some codes trigger prior authorization when retail cost exceeds $500 and age‑specific limitations apply for members younger than 21.

Prior Authorization

Air ambulance prior authorization

Non‑emergent air ambulance transport requires prior authorization for the listed codes.

Documentation Required

Laboratory services prior authorization contact

For laboratory services prior authorization contact LabCorp at 800-788-9743 as directed in the policy.

Prior Authorization

Out-of-network / Out-of-state prior authorization

Prior authorization is required for all out‑of‑network services; specific L‑codes are listed for out‑of‑network and out‑of‑state services and out‑of‑state benefits are approved only when emergent or unavailable in Arizona.

Prior Authorization

Therapy prior authorization workflow

Prior authorization is required after the initial evaluation and before the initial therapy visit and is required for all ongoing occupational and physical therapy visits.

Prior Authorization

Therapy prior authorization requirement

Therapy prior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits (age-specific distinctions apply in other sections).

Prior Authorization

Speech therapy coverage and prior authorization notes

For members younger than 21, outpatient speech therapy is covered when medically necessary with no annual benefit limits; prior authorization is required after the initial evaluation and before the initial visit and for ongoing therapy visits.

Prior Authorization

Radiology prior authorization

Advanced outpatient imaging (certain CT/MRI/MRA/PET and select nuclear medicine) requires prior authorization; submit via the Provider Portal Prior Authorization and Notification tool or call 866-889-8054.

Billing Rule

Pharmacy prior authorization contact and requirements

Pharmacy prior authorization is required for listed medications; service requests must include the 'J' codes and NDC codes. Pharmacy PA phone is 800-310-6826 and fax is 866-940-7328.

Prior Authorization

Procedure prior authorization list

Certain procedures (e.g., prostate procedures, proton beam therapy, rhinoplasty/septoplasty, shoulder surgery, sinuplasty and many surgical CPTs) require prior authorization as listed in the policy.

Prior Authorization

Prior authorization requirements (selected)

Prior authorization is required for the listed services and codes such as sleep apnea surgeries and certain durable medical equipment codes; skilled nursing facility services also require prior authorization.

Prior Authorization

Sterilization prior authorization and consent

Prior authorization is required for listed sterilization procedure codes and any member requesting sterilization must sign an appropriate Consent for Sterilization form as referenced in AMPM Chapter 400.

Prior Authorization

Stimulators prior authorization

Neurostimulator and related device implantation codes (including bone growth stimulators and neurostimulators) require prior authorization.

Prior Authorization

Transplant and CAR T-cell prior authorization and notification

Transplant services and CAR T‑cell therapies require prior authorization; clinical documentation must accompany requests and providers should call UnitedHealthcare Community and State Transplant Case Management at 800-418-4994 for specified CAR T products.

Prior Authorization

38232 PA rule

Code 38232 requires prior authorization only when billed for an oncology diagnosis.

Prior Authorization

Vein procedures, VAD and transportation prior authorization

Vein procedures and Ventricular Assist Device (VAD) related codes require prior authorization; for non‑emergent transportation schedule via MTM at 888-700-6822 and follow VAD notification instructions on the member ID card (fax forms to Optum VAD Case Management as directed).

Prior Authorization

Wound vac prior authorization

Wound VAC therapy (E2402) requires prior authorization.

DocumentationFor enteral/oral supplements in members <21, review AHCCCS Medical Policy (AMPM Chapter 400) and include CMN as applicable

Prior authorization definition

DefinitionPrior authorization: requirement to obtain approval from UnitedHealthcare before certain services, drugs, or devices are provided to ensure coverage

How to submitSubmit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the listed phone numbers for specific programs

ScopeApplies to many categories including chemotherapy injectables, selected procedures, DME, orthotics/prosthetics, and others listed in the policy

Certificate of Medical Necessity (CMN) for oral nutritional supplements

FormCertificate of Medical Necessity (CMN) for Commercial Oral Nutritional Supplements must accompany and establish medical necessity for enteral/oral supplement prior authorization requests

Where to findCMN available at azahcccs.gov > Resources > Guides-Manuals-Policies > AHCCCS Medical Policy Manual (AMPM) Chapter 400

DocumentationClinical documentation supporting need for TPN/TPN lipids and oral supplements must accompany requests

Incontinence supplies — vendor requirement

RequirementIncontinence supplies are a benefit only when provided through Preferred Homecare

How to requestTo request incontinence supplies, call Preferred Homecare (contact details in Provider Manual/portal)

Coverage noteRequests outside Preferred Homecare are not considered a covered benefit per policy notes

Optum Infusion prior authorization process

ProcessOptum Infusion is the contact point to request medications and in-home infusion services; call Optum Infusion at 888-705-4470

ScopePrior authorization is required for injectable medications and in-home infusion services not covered by Optum Infusion

CodesExamples of related J-codes listed in the document (see chemotherapy and injectable medication sections)

Hearing services / hearing aids prior authorization

RequirementHearing evaluations for members younger than 21 do not require prior authorization for specified CPT codes; hearing aids for members 21 and older require prior authorization

CodesEvaluation CPTs include 92590–92595; hearing aid supply codes include V5010–V5050

ActionSubmit prior authorization for hearing aids for members 21+ via the Provider Portal or as directed in the policy

Prior authorization and notification requirement for inpatient admissions and specified services

RequirementPrior authorization and notification of admission date required for acute care hospitals, acute inpatient rehabilitation, long-term acute care hospitals, and skilled nursing facilities

ExamplesNotification required for inpatient admissions and post-acute services; see inpatient admissions section for facility types

Transplant/CAR T noteTransplant and CAR T-cell services also require prior authorization and clinical documentation (see transplant section)

AHCCCS orthotics coverage conditions

Coverage conditionAHCCCS orthotics coverage applies when use is medically necessary and as preferred treatment; Medicare guidelines are referenced

Prior authorizationOrthotics and prosthetics codes listed require prior authorization; some codes include cost- and age-based limitations

Code examplesSample L-codes listed (L0112, L0462, L0484, L0859, L1830, etc.) with specific notes in the policy

Occupational and physical therapy coverage (no annual limits when medically necessary)

CoverageOccupational and physical therapy are covered when medically necessary with no annual benefit limits

Prior authorization workflowPrior authorization required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits (age-specific distinctions apply)

Age distinctionsRules differ for members <21 and ≥21; follow the age-specific guidance in the therapy section

Out-of-state services definition

DefinitionOut-of-state services: benefits approved only when the service is emergent or unavailable in Arizona

Prior authorizationOut-of-state and out-of-network services require prior authorization; specific L-codes listed for consideration

ActionInclude documentation supporting out-of-state or out-of-network request when submitting PA

Site of service (SOS) - outpatient

DefinitionSite of service (SOS) - outpatient: prior authorization only required when requesting service in an outpatient hospital setting

ExceptionPrior authorization is not required if the service is performed at a participating ambulatory surgery center (ASC)

ExamplesSOS designations provided for many CPTs (e.g., sinuplasty, gynecologic, and other surgical CPTs listed) to guide PA decisions

Pharmacy service request requirements (J codes and NDC required)

RequirementPharmacy service requests must include 'J' codes and NDC codes for the medication requested

ContactUnitedHealthcare Pharmacy Prior Authorization Service: Phone 800-310-6826; Fax 866-940-7328; specialty fax 866-940-7328

FormsFax forms and PA forms available at UHCprovider.com/AZcommunityplan > Pharmacy Resources

Site of service (SOS) general

DefinitionSite of service (SOS): designation indicating where a service is performed and whether PA is required based on location

UseSOS notes in code lists determine when outpatient hospital versus ASC impacts prior authorization requirements

ReferenceReview SOS entries for specific CPTs in the policy to determine PA need

Ventricular assist devices (VAD)

DefinitionVentricular assist devices (VAD): mechanical pumps that support damaged ventricles and require specialized management

Prior authorizationVAD-related codes require prior authorization; VAD case management notification process described

TransportationTo schedule non-emergent transportation call Medical Transportation Management (MTM) at 888-700-6822 and follow VAD notification instructions on member ID card; fax forms to Optum VAD Case Management at 855-282-8929

Stimulators definition (bone growth stimulator / neurostimulator)

DefinitionStimulators: devices (e.g., bone growth stimulators, neurostimulators) that send electrical impulses; listed implantation codes require prior authorization

CodesExamples of related CPT/HCPCS and implant codes are listed in the stimulators section of the policy (see 61863–61886 and L8680–L8688 series)

Prior authorizationPrior authorization required for implantation procedures and device-related codes; follow documentation requirements in the policy