CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas

Lists prior authorization requirements and how to submit requests for participating UnitedHealthcare Connected (Medicare‑Medicaid Plan) providers in Texas; includes codes, effective dates, and contact methods for authorization. Affects participating providers serving UnitedHealthcare Connected Texas members.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, chat 24/7, or fax 877-940-1972.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Oct 1, 2024document effective date

Portal + chat + faxsubmission methods

Texasgeographic scope

Prior auth regardless of amountDME/prosthetics rule

naviHealth

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Continued Care platform

Optum VADVAD case management

Prior Authorization and Notification Coverage Criteria

Prior authorization coverage criteria

Covered when specified codes/categories meet the listed prior authorization requirements and effective dates; includes special vendor and cost-threshold rules.

Prior authorization is required for the services and codes listed below as indicated by code group or category and effective date (see individual items).

Examples

Behavioral health services: many benefit plans route behavioral health through a designated behavioral health network; call 888-887-9003 when referring for mental health and substance use services.
Breast reconstruction (non-mastectomy) — CPT codes 19316, 19325, 19355: prior authorization effective Jan. 1, 2015. Prior authorization is not required for these codes when billed with Breast Reconstruction DX codes; required for other diagnoses.
Bone growth stimulator — codes 20974–20979: prior authorization effective Jan. 1, 2015.
BRCA genetic testing — code 81163: prior authorization effective Jan. 1, 2019.
Durable medical equipment (DME): prior authorization when cumulative rental cost exceeds $1,000 (see DME code listing).
Incontinence supplies: prior authorization is required through the service coordinator when not provided by Tenderheart Health Outcomes. To obtain from Tenderheart call 866-295-2319; to obtain from another provider call the service coordinator at 800-349-0550.
Prosthetics and certain DME: prior authorization is required regardless of billed amount for multiple listed prosthetic/DME codes (various effective dates referenced, e.g., July 1, 2017 / July 1, 2021).
Submission methods: prior authorization requests should be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com using One Healthcare ID), via 24/7 chat on the Contact Us page, or by fax to 877-940-1972. Prior authorization is not required for emergency or urgent care; out-of-network prior authorization requests must be submitted by a network care provider.

Prior authorization requirements (partial)

Selected procedures and treatments (partial list) require prior authorization as indicated below with codes and effective dates.

ANY of the following

Femoroacetabular impingement (FAI) codes: prior authorization effective July 1, 2017 (see FAI code entries).
Gender dysphoria treatment — codes 55970, 55980 and associated procedure codes: prior authorization effective Jan. 1, 2017; prior authorization required for these codes with any diagnosis (or only with Gender Dysphoria Treatment DX where specified).
Selected gender-affirming and related reconstructive procedure codes (examples listed: 14000, 14001, 14041, 15734, 15738, 15750, 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430 and others): follow the specific entry-level prior authorization notes and effective dates in the code list.
Hysterectomy (inpatient only) — codes 58260, 58262: prior authorization effective July 1, 2017; other hysterectomy-related codes listed with their respective entries and dates.

Authorization/Notification rules for listed code groups

Authorization and notification rules that apply across groups of listed codes.

Therapy: Initial evaluations do not require prior authorization; prior authorization is required for all re-evaluations and the other therapy codes listed. Prior authorization requests for therapy should be submitted online using the Prior Authorization and Notification tool at the UnitedHealthcare Provider Portal.

Orthotics: Prior authorization is required for orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000 (e.g., L3020 and related entries); effective date for many entries is Jan. 1, 2015.

Prosthetics: Prior authorization is required for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000; many prosthetic/DME codes also carry requirements regardless of billed amount.

Imaging notification: Care providers ordering an advanced outpatient imaging procedure are responsible for providing notification prior to scheduling the procedure.

Notification/prior authorization requirements (selected)

Notification and prior authorization requirements for selected specialty services with contact instructions where provided.

Stimulators / neurostimulator implantation (examples: E0747, E0748, L8682, L8683 and related device/procedure codes): prior authorization/notification required; many entries show effective dates (e.g., Jan. 1, 2015; July 1, 2021).

Transplant and CAR T-Cell therapies (examples: Q2055, Q2054, Q2053, C9399, J3590, 0537T, 0538T, 0539T, Q2042, Q2041): prior authorization/notification required. Contact the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's ID card for instructions.

Ventricular Assist Device (VAD): notification required. Call the notification number on the back of the member's health plan ID card, then fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929. Some VAD codes have prior authorization effective dates (example: Jan. 1, 2015).

Codes and Billing Categories

DME Codes and Prior Authorization Threshold

NotePrior authorization required when retail purchase or cumulative rental cost exceeds $1,000.

Submission Instructions and Provider Responsibilities

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com using One Healthcare ID). You may also connect via chat 24/7 using the Contact us page or fax requests to 877-940-1972. Prior authorization is not required for emergency or urgent care; out-of-network requests must be made by a network care provider.

Online: UHCprovider.com → Sign in with One Healthcare ID → Prior Authorization and Notification tab
Chat: 24/7 via Contact us page
Fax: 877-940-1972

Prior Authorization

Incontinence supplies prior authorization pathway

Incontinence supplies require prior authorization through the service coordinator when not provided by Tenderheart Health Outcomes. Obtain supplies from Tenderheart by calling 866-295-2319; to obtain from other providers call the service coordinator at 800-349-0550.

Tenderheart Health Outcomes: 866-295-2319

Key Terms and Program Definitions

Emergency/Urgent Care

RulePrior authorization is not required for emergency or urgent care.

Submission methodsPrior authorization requests may be submitted via Provider Portal (Prior Authorization and Notification tool), 24/7 chat, or fax to 877-940-1972

ApplicabilityApplies to UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas participating providers

Out-of-network requests

RequirementOut-of-network prior authorization requests must be submitted by a network care provider.

ContextThis is stated alongside submission instructions for prior authorization on the Provider Portal/Chat/Fax guidance

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Connected (Medicare‑Medicaid Plan) Texas

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, chat 24/7, or fax 877-940-1972.

SourceLink

On This Page

Additional listed procedures (partial): numerous procedure codes in the July 1, 2017–era listings require prior authorization per the code table — refer to the code-specific entries for exact effective dates and diagnostic restrictions.

Psychological testing: prior authorization effective Oct. 1, 2019; prior authorization will not be required for dates of service on or after Mar. 1, 2022 (see psychological testing code entries 96116, 96130, 96132, 96136).

Other provider / service coordinator: 800-349-0550

Prior Authorization

DME / Prosthetics prior authorization requirement

Prior authorization is required for many prosthetics and certain durable medical equipment (DME) regardless of billed amount; multiple HCPCS/E-codes are listed in the DME/prosthetics sections of the policy.

Policy lists numerous prosthetic/DME HCPCS and E-codes subject to prior authorization
Requirement applies regardless of billed amount

Prior Authorization

Prior authorization submission for Continued Care

Submit prior authorization requests for post-acute inpatient Continued Care through naviHealth; prior authorization and notification of the admission date are required for the listed facility types.

Use naviHealth as part of the Continued Care program
Phone for Continued Care program: 855-851-1127
Applies to acute care hospitals, inpatient rehab, critical access hospitals, LTACs, and skilled nursing facilities

Prior Authorization

Transport / Ambulance prior authorization

Non‑emergent air and ground transport services require prior authorization per the listed transport codes and effective dates; Texas ground ambulance services are subject to the TX mandate with prior authorization effective dates noted in the policy.

Non-emergent air transport codes (e.g., A0430, A0435, A0431, A0436) subject to prior authorization (effective Jan. 1, 2015)
Non-emergent ground transport codes (e.g., A0420, A0424, A0426) subject to prior authorization (effective Apr. 1, 2016)
Texas ground ambulance TX mandate codes listed in policy

Prior Authorization

Joint replacement prior authorization

Total hip and knee replacement procedures require prior authorization; the policy lists joint replacement codes with a prior authorization effective date of Jan. 1, 2015.

Joint replacement (total hip and knee) prior authorization effective Jan. 1, 2015
Specific CPT codes for joint replacement are enumerated in the policy

Prior Authorization

Orthognathic / maxillofacial surgery prior authorization

Orthognathic and related maxillofacial/jaw procedures require prior authorization; the policy lists multiple CPT codes for orthognathic and jaw surgeries with prior authorization requirements (various effective dates).

Orthognathic surgery codes included (examples: 21120, 21121, 21122, 21123, 21125, 21127, 21141)
Prior authorization effective date for many listed codes is Jan. 1, 2015 (per policy)

Prior Authorization

Submission instruction for therapy prior authorization

Therapy prior authorization requests should be submitted online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. Initial therapy evaluations do not require prior authorization; all re-evaluations and the other listed therapy codes do.

Submit via UnitedHealthcare Provider Portal → Prior Authorization and Notification
Initial evaluations: no prior authorization required
All re-evaluations and listed therapy codes: prior authorization required

Prior Authorization

Orthotics cost threshold for prior authorization

Prior authorization is required for orthotics codes listed when the retail purchase or cumulative rental cost exceeds $1,000.

Cost threshold: retail purchase or cumulative rental cost of more than $1,000 triggers prior authorization
Example orthotics code listed: L3020

Prior Authorization

Prosthetics cost threshold for prior authorization

Prior authorization is required for prosthetic codes listed when the retail purchase or cumulative rental cost exceeds $1,000.

Cost threshold: retail purchase or cumulative rental cost of more than $1,000
Policy notes multiple prosthetic HCPCS/L codes subject to this threshold

Documentation Required

Imaging notification responsibility

Care providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling the procedure.

Applies to the radiology/imaging codes listed in the policy
Notification must occur before scheduling the advanced outpatient imaging

Prior Authorization

VAD notification and prior authorization instructions

Ventricular Assist Device (VAD) placements require notification; call the notification number on the back of the member's health plan ID card and fax the nurse‑provided form to Optum VAD Case Management at 855-282-8929.

Call the notification number on the back of the member's ID card
Fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929

Prior Authorization

Transplant and CAR T-Cell prior authorization

Transplant and CAR T‑Cell therapy services require prior authorization/notification; contact the UnitedHealthcare Community and State Transplant Case Management team or use the notification number on the member's ID card for instructions.

Contact Community and State Transplant Case Management team at 888-936-7246
Some CAR T‑Cell and transplant codes have specific prior authorization effective dates listed in the policy

Applies toUnitedHealthcare Connected Texas prior authorization process

Continued Care Program

ProgramContinued Care Program requires prior authorization and notification of admission date for listed post-acute inpatient facilities

Facilities includedAcute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, skilled nursing facilities

Submission platformSubmit prior authorization requests through naviHealth as part of the Continued Care program

Phone855-851-1127

naviHealth

PlatformnaviHealth is the submission platform for prior authorization requests for post-acute inpatient services (Continued Care Program).

Use caseUsed when submitting prior authorization and notification of admission date for specified post-acute facilities

ContactPhone: 855-851-1127

Initial evaluation (therapy) / Re-evaluation

Therapy evaluationsInitial evaluations do not require prior authorization.

Re-evaluations and other therapy codesPrior authorization is required for all re-evaluations and other listed therapy codes (prior authorization effective date: July 1, 2017 for listed groups).

SubmissionPrior authorization should be submitted online using the Prior Authorization and Notification tool at the UnitedHealthcare Provider Portal.

Cost threshold for prior authorization

ThresholdRetail purchase or cumulative rental cost greater than $1,000 triggers prior authorization for orthotics and prosthetics

Applies toOrthotics codes (e.g., L3020) and prosthetics codes listed in their respective sections

ActionSubmit prior authorization when aggregate retail cost or cumulative rental cost exceeds $1,000

Ventricular Assist Device (VAD)

DefinitionVentricular Assist Device (VAD): A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

Codes referencedExamples include 33975, 33979, 33982, 33976, 33981, 33983

Notification instructionCall the notification number on the back of the member's health plan ID card, then fax form to Optum VAD Case Management at 855-282-8929

Stimulators / Neurostimulator

DefinitionStimulators / Neurostimulator: implantation of a device that sends electrical impulses (includes bone growth stimulator codes E0747, E0748 and implantable neurostimulator codes L8682, L8683).

ExamplesBone growth stimulator: E0747, E0748; Neurostimulator: L8682, L8683; related CPTs for implantation also listed in stimulator section

Prior authorization effective datesSome stimulator codes list effective dates (e.g., Jan. 1, 2015 for bone growth stimulators; July 1, 2021 for neurostimulator implant codes)