UnitedHealthcare Prior Auth Requirements AZ DD

Coverage Criteria and Requirements

Coverage notes and criteria (partial)

High-level coverage notes and examples found in this section:

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

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

Experimental and investigational services are not covered benefits.

All rendering providers, facilities and vendors must be actively registered with AHCCCS; only one health care professional may request services on a prior authorization form.

Allergy immunotherapy and testing

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 subcutaneous injections and sublingual routes) is not a covered benefit except when the member has sustained an anaphylactic reaction to an unknown allergen or has exhibited a severe allergic reaction where further exposure may be life‑threatening (examples: severe facial swelling, breathing difficulties, epiglottal swelling, extensive urticaria).

Only medically necessary, cost‑effective, federal‑ and state‑reimbursable services are covered as outlined by AHCCCS.

Services delivered inside multi‑specialty interdisciplinary CRS clinics to CRS‑designated/formerly designated members do not require prior authorization.

Cosmetic/Reconstructive procedures

Prior authorization required for specified CPT/HCPCS codes; cosmetic procedures furnished solely for cosmetic purposes are excluded per AHCCCS guidance.

Prior authorization is required for the cosmetic and reconstructive CPT/HCPCS codes listed in the Prior Authorization and Notification Resources on UHCprovider.com/AZcommunityplan.

Procedures and services furnished solely for cosmetic purposes (to improve appearance without treating or restoring physiologic function) are excluded from coverage.

Code examples (partial)

Examples include CPT codes such as 11960, 14020, 17106, 21137 (see provider portal lists for full code sets).

For full lists and how to obtain prior authorization, providers must consult UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources.

DME and prosthetics

Durable medical equipment (DME) and prosthetics: many specific E/K codes listed; certain items not covered by Preferred Homecare; some DME requires prior authorization regardless of dollar amount.

To request DME items or DME prior authorization, call Preferred Homecare at 800-636-2123.

Certain DME requires prior authorization regardless of dollar amount when cost is more than $500.

Examples of DME items requiring authorization or vendor processing

Bone stimulators (E0656 and related E-codes).
Insulin pumps (E0745 and related E-codes).
Wound vacuum devices (E1009 and related E-codes).

Enteral and parenteral nutrition

Enteral/parenteral/oral in-home nutritional therapy (including TPN and oral supplements) requires prior authorization via Preferred Homecare with clinical documentation and certificate of medical necessity.

Requests for enteral, gastrostomy, total parenteral nutrition (TPN), lipids and oral supplements must be submitted by calling Preferred Homecare at 800-636-2123.

Clinical documentation and an oral supplement certificate of medical necessity, as applicable, must accompany the request to establish medical necessity.

Coverage and prior authorization criteria (excerpt)

Summary of coverage and prior authorization rules appearing in this segment:

For members younger than 21: certain benefits (for example, one routine eye exam every 12 months and specified lens/frame allowances) are provided per the listed pediatric benefits.

For members 21 and older: prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye; selected surgical and device procedures (e.g., femoroacetabular impingement codes, FESS) require prior authorization.

Genetic testing for services not covered by LabCorp requires prior authorization; providers should call LabCorp to determine requirements.

Hearing evaluations and hearing aids for members 21 and older require prior authorization; pediatric hearing aids differ (prior authorization may not be required).

Infusion and in-home injectable medications not covered by Optum Infusion require prior authorization; contact Optum Infusion at 800-985-3059 to request medications or supplies.

Coverage requirements for injectables and inpatient services

Injectable medications listed require prior authorization for members 21 and older; inpatient admissions require prior authorization/notification.

Prior authorization is required for the injectable medications listed for members aged 21 and older (refer to the document lists and J-codes).

For inpatient admissions and specified post‑acute settings (acute care hospitals, acute inpatient rehabilitation, long‑term acute care hospitals), prior authorization and notification of the admission date are required.

Predetermination (advance review) is highly recommended for drugs on the list; submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Prior authorization/notification criteria (members 21+)

Services and codes requiring prior authorization or notification for members age 21 and older.

Inpatient admissions and post‑acute services (acute care hospitals, acute inpatient rehabilitation, long‑term acute care hospitals): prior authorization and notification of admission date required.

Joint replacement procedures (total hip and knee) require prior authorization for the listed CPT codes; predetermination is recommended.

Certain laboratory services and nonemergent air ambulance transports require prior authorization for the listed codes; contact the plan or use the provider portal to determine requirements.

Orthognathic and maxillofacial procedures listed require prior authorization for the specified CPT/HCPCS codes.

Orthotics/Prosthetics Prior Auth and Coverage

Orthotics and prosthetics prior authorization and coverage notes

Prior authorization is required for orthotics and prosthetic HCPCS L‑codes listed for members 21 and older; submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Reasonable repairs or adjustments of purchased orthotics are covered for members.

Documentation must establish medical necessity and, when applicable, that the component is not functioning or must be replaced per the listed L‑codes and criteria.

Coverage criteria summary

Coverage and prior authorization criteria summarized by service and member age group.

Orthotics/prosthetics for members 21+: many HCPCS L‑codes listed; prior authorization required for specific components, replacements and repairs; out‑of‑network services require prior authorization.

Outpatient therapy for members younger than 21: listed CPT codes (speech, OT, PT and related codes) require prior authorization as specified. Outpatient speech therapy is not a covered benefit for members 21 and older.

Occupational and physical therapy are limited to 15 visits per benefit year (Oct 1 - Sept 30) for restoration/maintenance or acquisition/maintenance of skills; qualified Medicare beneficiaries are covered for unlimited visits when medically necessary.

Pain injections and management require prior authorization (e.g., codes 64490, 64493).

A list of pharmacy and physician‑administered drugs require prior authorization; service requests must include J‑codes and NDCs where applicable and follow the pharmacy prior authorization contact/process.

Coverage criteria and prior authorization requirements

Summary of coverage and prior authorization expectations

Occupational and physical therapy are limited to 15 visits per benefit year (Oct. 1 - Sept. 30) for restoration/maintenance or acquisition/maintenance of skills.

Qualified Medicare beneficiaries: unlimited OT/PT visits when medically necessary.

Pharmacy and specialty pharmacy prior authorization required for listed medications; service requests must include medication J‑codes and NDCs; contact UnitedHealthcare Pharmacy Prior Authorization by phone or fax and use drug‑specific forms available on UHCprovider.com/AZcommunityplan.

Providers ordering advanced outpatient imaging procedures are responsible for notification prior to scheduling and must submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool; fax forms are available.

Prior authorization requirement

Prior authorization required for listed codes or categories as noted in the segment.

Prior authorization is required for specialty/enclosed beds and other DME codes listed (see HCPCS E‑codes in the DME section); fax forms are available.

Selected procedures (for example, sleep apnea procedures and surgeries) have CPT/HCPCS codes listed that require prior authorization; providers should use fax forms or portal submission as instructed.

Transplant prior authorization and documentation

Transplant services requirements

Transplant and CAR T‑Cell therapy services require prior authorization; clinical documentation to support the need for transplant must accompany and establish medical necessity for the request.

For transplant and CAR T‑Cell therapy services (including named therapies such as Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta and others), contact the UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 for prior authorization and notification instructions.

Sterilization prior authorization and consent requirements

Sterilization

Sterilization procedures require prior authorization for the listed CPT codes (for example 52601, 52630, 52647, 52648, 52649, 55250, 55801, 55821, 55831, 58600, 58605, 58611) and appropriate sterilization consent forms must be completed per AHCCCS guidance.

Refer to AHCCCS AMPM Chapter 400, Section 420, for sterilization consent forms and additional guidance.

Authorization requirements

Prior authorization requirements and contact instructions for devices/procedures referenced.

Ventricular assist devices (VADs) require prior authorization; providers should call the notification number on the member's health plan ID card and then fax the nurse‑provided form to the Optum VAD Case Management team at 855-282-8929.

Wound vacuum devices (e.g., E2402) require prior authorization for the listed codes.

Cardiac and vascular device codes (examples)

VAD procedure codes include 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983 and related HCPCS Q‑codes (Q0507–Q0509).

How Providers Request Authorizations and Operational Steps

Prior Authorization

How to request prior authorization

To request prior authorization: submit online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID) or call the phone numbers shown for the specific service area. See specialty program pages on UHCprovider.com/AZcommunityplan for code lists and additional instructions.

Online: UHCprovider.com > Sign In > Prior Authorization and Notification tool
Phone: 800-445-1638 (general) — use specialty numbers where noted in service entries

Note

Prior authorization prerequisites and exclusions

Prior authorization applies only to services that are covered benefits under AHCCCS and provided by registered, participating providers. Services that are experimental/investigational are not covered. Services provided by non-network or out-of-state providers generally require prior authorization with supporting documentation. Services delivered inside CRS-designated multidisciplinary CRS clinics do not require prior authorization. Only one provider may submit a prior authorization request per request form.

Member eligibility and AHCCCS coverage rules apply
Non-network/out-of-state requests require documentation
CRS clinic services exempt from prior authorization
Only one requesting provider per request

Documentation Required

Provider registration and request rules

Providers must be actively registered with AHCCCS and follow the portal or phone/fax submission rules for the service requested. Use the specialty contact numbers and fax forms listed in each service entry (see 'Fax forms are available at' notes) where applicable. Predetermination is highly recommended for certain high-cost procedures and new-to-market medications (see Review at Launch guidance).

AHCCCS registration required for all rendering providers, facilities and vendors
Use specialty portal pages and service-specific fax forms when available
Predetermination recommended for listed drugs and high-cost services

Note

CRS clinic prior authorization exemption

Services delivered inside children's rehabilitative services (CRS)-designated multispecialty interdisciplinary clinics do not require prior authorization.

CRS clinic services exempt from prior authorization

Note

Specialty-specific portal guidance

Specialty programs (for example: Cardiology, Radiology, Transplant, Pharmacy, VAD/Ventricular Assist Device) often have their own portal pages, contact numbers and program-specific submission forms. Always consult the applicable Prior Authorization and Notification Resources page on UHCprovider.com/AZcommunityplan for the most current code lists and instructions.

Visit UHCprovider.com/AZcommunityplan > Prior Authorization and Notification Resources for specialty guidance
Use program-specific phone/fax numbers and forms listed on the specialty pages

Prior Authorization

Cosmetic and reconstructive procedures prior auth

Cosmetic and reconstructive procedures listed require prior authorization unless otherwise noted (for example, some codes do not require prior authorization when billed with skin cancer). Consult the cosmetic/reconstructive entries and specialty resources on the provider portal for full code lists and rules.

Prior authorization required for listed cosmetic/reconstructive CPT/HCPCS codes
Some exceptions apply (see code notes on portal)

Note

Dental prior auth contact

For dental prior authorization requirements and to request dental authorizations, contact UnitedHealthcare Dental at 855-812-9208.

UnitedHealthcare Dental: 855-812-9208

Prior Authorization

DME prior auth and vendor

Durable medical equipment (DME) and many home medical supplies are managed through Preferred Homecare. To request DME items or incontinence supplies provided through Preferred Homecare, call Preferred Homecare at 800-636-2123. DME items may require prior authorization regardless of dollar amount; follow Preferred Homecare or plan guidance for items not covered by Preferred Homecare.

Preferred Homecare (DME and incontinence supplies): 800-636-2123
Incontinence supplies and some home infusion items benefit only when provided through Preferred Homecare

Prior Authorization

Enteral/parenteral nutrition prior auth

Enteral, parenteral and oral in-home nutrition therapy (including TPN, lipids and oral supplements) require prior authorization. To request services and supplies, call Preferred Homecare at 800-636-2123. Include clinical documentation and, where applicable, an oral supplement certificate of medical necessity to establish medical necessity with the request.

Preferred Homecare (enteral/parenteral/oral nutrition): 800-636-2123
Clinical documentation and certificate of medical necessity (for oral supplements) must accompany requests

Documentation Required

Enteral/parenteral and oral nutritional therapy prior authorization

For enteral/parenteral and oral nutritional therapy, ensure clinical documentation and any required certificates of medical necessity accompany the authorization request to demonstrate medical necessity.

Attach clinical documentation and oral supplement CMN as applicable

Prior Authorization

Eye care prior authorization/contact

For eye care services (members 21 and older), prior authorization is required when medically necessary to diagnose or treat eye diseases and conditions. For member eye care services, contact Nationwide Vision at 480-961-1702.

Nationwide Vision (member eye care services): 480-961-1702
Prior authorization required for medically necessary eye services for members 21+ where noted

Prior Authorization

Infusion and in-home injectable medications

Infusion and in-home injectable medication services are managed through specified vendors. Prior authorization is required for services not covered by the vendor. To request medications or infusion services through Optum Infusion, call 800-985-3059. For injectable physician-administered drugs and specialty pharmacy prior authorizations, use the Pharmacy Prior Authorization contact (phone/fax) listed in the pharmacy section.

Optum Infusion (medication/infusion requests): 800-985-3059
Pharmacy prior authorization phone: 800-310-6826; fax: 866-940-7328

Prior Authorization

Genetic testing prior authorization

Genetic testing not covered by LabCorp requires prior authorization. To determine prior authorization requirements for genetic testing, contact LabCorp at 800-788-9743. Use the LabCorp guidance to confirm which genetic tests need prior authorization.

LabCorp genetic testing prior authorization inquiries: 800-788-9743
Prior authorization required for genetic testing services not covered by LabCorp

Prior Authorization

Procedure and device prior authorization notes (vision, ENT, orthopedics, hearing)

Procedures and devices such as vision-related surgeries, ENT procedures, orthopedic surgeries and hearing services may require prior authorization. Consult the specific entries and code lists in this document and on the provider portal for code-level prior authorization rules and any device-related requirements.

Consult UHCprovider.com/AZcommunityplan specialty resources for code lists
Hearing aids and services prior authorization details available in hearing section

Prior Authorization

Inpatient and post-acute prior authorization / notification

Notification is required for inpatient admissions and some post-acute services. Predetermination is highly recommended for listed drugs and high-cost services. Submit inpatient admission notifications and prior authorizations using the Provider Portal Admission/Notification tools or the inpatient notification numbers referenced on the member ID card and in the specialty sections.

Inpatient admission and post-acute notification required for acute care hospitals, acute inpatient rehabilitation and long-term acute care hospitals
Use Provider Portal or notification numbers on member ID card

Note

Reference for new-to-market medications

For medications that are new-to-market, check the 'Review at Launch for New to Market Medications' policy for current prior authorization and predetermination guidance. The Review at Launch policy is available on UHCprovider.com under Community Plan medical and drug policies.

Review at Launch for New to Market Medications available at UHCprovider.com/policies > For Community Plans

Prior Authorization

Prior authorization required for selected procedures and inpatient services

Prior authorization and notification are required for joint replacement procedures, spinal surgeries, transplant services, stimulator/device implantations, and many other listed high-cost surgical services. Use the Prior Authorization and Notification tool and specialty program contacts; predetermination is recommended where indicated.

Joint replacement and spinal surgery codes listed in this document require prior authorization
Transplant and CAR T-cell therapies: contact UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994

Prior Authorization

Orthotics/prosthetics prior auth and repairs

Orthotics and prosthetics require prior authorization. See the orthotics/prosthetics code entries (L-codes) and use the Provider Portal prior authorization workflow. Predetermination is recommended where noted.

Orthotics/prosthetics HCPCS L-codes (examples L0112, L0170, L0456, L0462, L0464, L0480, L8043-L8659) require prior authorization as listed

Prior Authorization

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

Out-of-network and out-of-state services require prior authorization except for emergent services or when the service is not available in Arizona. Documentation supporting out-of-network or out-of-state requests must accompany the authorization request.

Out-of-network services prior authorization required
Out-of-state services limited to emergent or unavailable-in-state situations

Prior Authorization

Outpatient therapy prior authorization and codes

Outpatient therapy (occupational, physical, speech) codes and limits are described in the outpatient therapy entries. Prior authorization may be required for specific codes and limits apply (for example, visit limits for members under 21 may differ). Review the therapy entries for code-level prior authorization and visit limit rules.

Outpatient therapy CPT codes listed in therapy sections
Visit limits (example: 15 OT/PT visits per benefit year for certain services)

Prior Authorization

Pain injections prior authorization

Pain injections and pain management procedures listed require prior authorization. Include CPT codes for requested injections when submitting the request.

Pain injection CPT examples: 64490, 64493
Include procedure codes in the request

Prior Authorization

Pharmacy prior authorization process and contact

For pharmacy prior authorization: submit requests to UnitedHealthcare Pharmacy Prior Authorization service. Phone: 800-310-6826. Fax: 866-940-7328. Specialty pharmacy prior authorization fax: 866-940-7328. Fax forms and drug-specific service request forms are available at UHCprovider.com/AZcommunityplan > Pharmacy Resources & Physician Administered Drugs > Pharmacy Prior Authorization.

Pharmacy prior authorization phone: 800-310-6826
Pharmacy prior authorization fax (and specialty fax): 866-940-7328
Fax forms available on UHCprovider.com/AZcommunityplan

Prior Authorization

Prior authorization requirements for selected procedures and imaging

Certain advanced outpatient imaging procedures (CT/MRI/MRA/PET, nuclear medicine, nuclear cardiology) require prior authorization. Ordering providers are responsible for notification prior to scheduling. Use the Provider Portal Prior Authorization and Notification tool for these imaging requests.

Ordering provider must notify prior to scheduling advanced outpatient imaging
Submit imaging prior authorizations via Provider Portal

Note

How to obtain prior authorization

How to obtain prior authorization: submit requests through the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID). For service-specific phone/fax numbers and forms, consult the specialty entries in this document and the portal resource pages.

UHCprovider.com > Sign In > Prior Authorization and Notification tool
Use specialty phone/fax and forms as listed in the policy entries

Prior Authorization

Specialty/enclosed beds prior authorization

Specialty and enclosed beds (complex durable medical equipment such as specialty beds) require prior authorization. See the Specialty/enclosed beds entry for HCPCS codes (for example E0250–E0294 series) and follow the Provider Portal submission process.

Specialty/enclosed beds HCPCS examples: E0250, E0251, E0255, E0256, E0260–E0294
Prior authorization required and fax forms available

Prior Authorization

Sleep apnea procedures prior authorization

Sleep apnea procedures and surgeries listed require prior authorization. Consult the sleep apnea section for CPT/HCPCS codes and submit requests via the Provider Portal.

Sleep apnea procedure codes listed in the policy require prior authorization

Prior Authorization

Durable medical equipment prior authorization

Durable medical equipment (DME) prior authorization — see DME entries and Preferred Homecare contact for item requests and prior authorization processing.

Preferred Homecare: 800-636-2123
DME prior authorization required for listed items

Prior Authorization

Spinal surgery prior authorization

Spinal surgery procedures listed require prior authorization. Use the Provider Portal and include required clinical documentation with the request. Fax forms for spinal surgery authorizations are available where noted.

Spinal surgery CPT examples listed in policy (22100–22856, 63001–63020, etc.) require prior authorization
Include clinical documentation; fax forms available as noted

Documentation Required

Sterilization prior authorization and consent

Sterilization procedures require prior authorization and appropriate consent. Follow AHCCCS consent requirements and include the signed Consent to Sterilization form when applicable.

Sterilization CPT examples: 52601, 52630, 52647–52649, 55250, 55801, 55821, 55831, 58600, 58605, 58611, 58615, 58670, 58671, 58700
Include required sterilization consent documentation per AHCCCS guidance

Prior Authorization

Neurostimulator and device implantation prior authorization

Neurostimulator and other electronic device implantations require prior authorization. Codes and device HCPCS/L-codes are listed in the stimulator/device sections. Provide device details and supporting clinical documentation when requesting authorization.

Neurostimulator CPT/HCPCS examples listed (63650, 63655, 63685, 64553, 64555, 64568, 64570, 64590, L8680–L8688) require prior authorization
Provide full device information and clinical documentation

Prior Authorization

Transplant and other surgical services prior authorization

Transplant services and CAR T-cell therapies require prior authorization and specific transplant case management coordination. For transplant and CAR T-Cell therapy services (including listed CAR T products), contact UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994. Clinical documentation to support the need for transplant must accompany the request.

Transplant/CAR T therapies contact: 800-418-4994
Clinical documentation to establish medical necessity is required

Prior Authorization

Oncology-specific prior authorization notes

Oncology-specific prior authorization notes: certain oncology procedures, chemotherapy injectable drugs (J9000–J9999 and other oncology J-codes), and CAR T-cell therapies have program-specific prior authorization processes. Use the oncology and physician-administered drug resources on the provider portal and specialty contacts listed in this policy.

Chemotherapy injectable drugs (J9000–J9999 and listed agents) require prior authorization
Use provider portal oncology/drug resources and program contacts

Prior Authorization

Transportation prior authorization and scheduling

Transportation prior authorization is required for nonemergent taxi and stretcher van transport. To schedule transportation, call Medical Transportation Management at 888-700-6822.

Medical Transportation Management: 888-700-6822
Nonemergent taxi and stretcher van require prior authorization

Prior Authorization

Vein procedure prior authorization

Vein procedures (removal and ablation of saphenous trunks and named branches) listed require prior authorization. Refer to the policy code list and submit requests through the Provider Portal.

Vein procedure CPT examples: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766
Prior authorization required for listed vein procedure codes

Prior Authorization

VAD notification and fax process

Ventricular assist devices (VADs) require prior authorization and notification. Call the notification number on the back of the member's health plan ID card first. Then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929. Include the completed form and clinical documentation to support the need for the VAD. For code-level billing, see the VAD procedure codes listed in the policy (for example 33927, 33928, 33929, 33975–33983, Q0507–Q0509).

Call the notification number on the back of the member's ID card before placement/arrangement
Fax the nurse-provided VAD form and supporting clinical documentation to Optum VAD Case Management: 855-282-8929
VAD procedure billing examples: 33927, 33928, 33929, 33975–33983, Q0507–Q0509

Note

Prior authorization and contact instructions

For any prior authorization question where a service-specific contact is not listed, use the general Prior Authorization and Notification tool on the Provider Portal or call the general number on the member's ID card. Always attach relevant clinical documentation and applicable procedure or drug codes (CPT, HCPCS, J-codes, NDC) to expedite review.

Include CPT/HCPCS/J-codes/NDCs on all requests
Use Provider Portal or member ID card general contact if service-specific contact not listed

Definitions and Key Terms

Covered benefit (AHCCCS)

DefinitionCovered benefits must be services as defined by the Arizona Health Care Cost Containment System (AHCCCS) to be eligible for prior authorization.

ExclusionsExperimental and investigational services are not covered benefits under AHCCCS rules.

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

EPSDT

AcronymEPSDT — Early and Periodic Screening, Diagnostic and Treatment.

Coverage noteAllergy immunotherapy and allergy testing are covered under EPSDT when medically necessary for members younger than 21.

Age-specific ruleFor members 21 and older, allergy immunotherapy is not a covered benefit except in life-threatening/severe anaphylactic cases.

UnitedHealthcare Dental prior authorization

ContactUnitedHealthcare Dental prior authorization requests: call 855-812-9208.

ScopeUse this contact for dental prior authorization requirements referenced in the document.

ReferenceSee dental section for code-specific prior authorization notes (e.g., certain CPT/HCPCS codes listed).

Preferred Homecare requests

VendorPreferred Homecare — primary contact for requesting DME and enteral/parenteral nutrition services.

Phone800-636-2123 — to request DME items or enteral/parenteral/oral in‑home nutritional therapy.

Documentation requiredClinical documentation and certificate of medical necessity (as applicable) must accompany requests to establish medical necessity.

Vendors/providers for homecare, supply, infusion and in-home medication

Primary vendors/providersPreferred Homecare and Optum Infusion are the vendors/providers for homecare supplies, infusion and in-home medications as noted.

Optum Infusion phoneOptum Infusion: 800-985-3059 for infusion/in-home injectable medication requests and supply ordering.

Preferred Homecare phonePreferred Homecare: 800-636-2123 for DME and enteral/parenteral nutrition requests.

Contact for determining prior authorization requirements for genetic testing

ContactLabCorp prior authorization line: call 800-788-9743 to determine prior authorization requirements for genetic testing.

ScopePrior authorization is required for genetic testing services not covered by LabCorp; contact LabCorp to confirm requirements and codes.

ExamplesMultiple genetic testing CPT codes are referenced; use LabCorp contact to verify specific prior auth needs.

Predetermination is recommended

RecommendationPredetermination is highly recommended for drugs on the list (advance review of coverage/authorization prior to service or admission).

How to performSubmit predetermination/prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com -> Sign In).

Related policySee the 'Review at Launch for New to Market Medications' policy for details on newly FDA‑approved drugs and predetermination guidance.

Review at Launch for New to Market Medications policy reference

Policy referenceReview at Launch for New to Market Medications — consult this UnitedHealthcare policy for up‑to‑date handling of newly FDA‑approved drugs.

Where to findAvailable at UHCprovider.com/policies > For Community Plans > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

Use caseReference when a medication on the list is newly FDA‑approved or when guidance on new therapies is needed.

Notification of admission date required

RequirementNotification of admission date is required for inpatient admissions and post‑acute services (acute care hospitals, acute inpatient rehabilitation, long‑term acute care hospitals).

Submission methodSubmit prior authorization and admission notifications via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com).

Predetermination notePredetermination is highly recommended for drugs on the list when planning inpatient admissions.

Predetermination (recommended for drugs on the list)

RecommendationPredetermination is recommended for drugs on the prior authorization list prior to service or admission.

Medication request requirementsService requests for medications must include J‑codes and NDCs for the medication requested.

Pharmacy contactUnitedHealthcare Pharmacy Prior Authorization phone: 800-310-6826; fax: 866-940-7328.

Predetermination

Predetermination and portal usePredetermination and prior authorization requests should be submitted online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com -> Sign In).

Advanced imagingHealth care professionals ordering advanced outpatient imaging (CT, MRI, MRA, PET, nuclear medicine) must provide notification prior to scheduling and submit requests via the portal.

Fax formsFax forms are available at UHCprovider.com/AZcommunityplan for many services if required.

Repairs/adjustments coverage

Repairs/adjustmentsReasonable repairs or adjustments of purchased orthotics are covered for members.

Prior authorizationPrior authorization is required for orthotics and prosthetic codes (L‑codes) listed for members 21 and older.

SubmissionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool.

Out-of-state services approval conditions

Approval conditionsOut‑of‑state services are approved only when emergent or the required service is unavailable in Arizona.

Out‑of‑networkPrior authorization is required for all out‑of‑network services and must include supporting documentation.

Where notedSee orthotics/prosthetics and other sections for specifics on out‑of‑state or out‑of‑network prior authorization rules.

Outpatient speech therapy not covered for members 21+

Coverage statusOutpatient speech therapy is not a covered benefit for members 21 and older.

Younger membersSpeech therapy coverage and prior authorization rules differ for members younger than 21 (see outpatient therapy section).

Related servicesOccupational and physical therapy remain covered (subject to visit limits) for applicable settings.

Advanced outpatient imaging

DefinitionAdvanced outpatient imaging includes certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures.

Provider responsibilityProviders ordering advanced outpatient imaging must provide notification prior to scheduling and submit prior authorization requests via the UnitedHealthcare Provider Portal.

ResourcesFax forms and radiology prior authorization resources are available at UHCprovider.com/AZcommunityplan.

Medication service request requirements (J-codes and NDCs)

Required dataMedication service requests must include the medication's J‑code and NDC code when applicable.

Pharmacy PA contactsUnitedHealthcare Pharmacy Prior Authorization phone: 800-310-6826; fax: 866-940-7328. Specialty pharmacy PA fax: 866-940-7328.

Form availabilityFax forms and drug‑specific service request forms are available at UHCprovider.com/AZcommunityplan Pharmacy Resources/Physician Administered Drugs.

Site of service (SOS) - outpatient

DefinitionSite of service (SOS) — outpatient: many procedures listed are expected to be performed in an outpatient site of service; prior authorization/SOS rules apply.

ExamplesOphthalmologic CPT examples (e.g., 65710, 66710) and arthroscopic/shoulder codes are listed with SOS = outpatient expectations.

Provider actionConfirm site‑of‑service prior to scheduling and submit prior authorization/notification as required.

Transplant Case Management Team contact

Transplant Case ManagementUnitedHealthcare Community and State Transplant Case Management Team — call 800-418-4994 for transplant and CAR T‑Cell therapy services.

DocumentationClinical documentation must accompany and establish medical necessity for transplant requests.

Named therapiesFor CAR T‑cell and named therapies (e.g., Abecma, Yescarta, Tecartus), contact the Transplant Case Management Team or follow the notification instructions provided.

Optum VAD Case Management fax process

Fax processOptum VAD Case Management fax: 855-282-8929. Providers should call the notification number on the member's ID card first, then fax the nurse‑provided form to this number.

Use caseThis process applies to ventricular assist device (VAD) prior authorization and notification actions.

Where notedDetails and forms referenced in the VAD section of the document; fax forms available at indicated provider resources.

Ventricular assist device (VAD)

Device definitionVentricular assist device (VAD) — mechanical pump devices with associated CPT/HCPCS codes listed (e.g., 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, 33983, Q0507‑Q0509).

Prior authorizationPrior authorization is required for listed VAD procedure and HCPCS codes; follow the notification and fax process to Optum VAD Case Management.

Contact stepsCall the notification number on the member's ID card, then fax the nurse‑provided VAD form to 855-282-8929.

Wound vac definition

DefinitionWound vac — vacuum‑assisted wound closure devices (example HCPCS: E2402).

Prior authorizationPrior authorization is required for wound vac codes listed in the document.

How to requestFollow the general DME prior authorization instructions and submit requests via Preferred Homecare or the Provider Portal as applicable.

J1459	Immune globulin, intravenous, non-lyophilized (e.g., 10% solution), 500 mg
J1551	Injection, lanreotide, per 1 mg
J1556	Injection, pamidronate disodium, 1 mg
J1566	Injection, ibandronate sodium, 1 mg
J1575	Injection, zoledronic acid, 1 mg

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Prior authorization requirements for Arizona Developmental Disabilities

Coverage Criteria and Requirements

CPT / HCPCS / Drug Codes and Coding Notes

How Providers Request Authorizations and Operational Steps

Definitions and Key Terms