CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Indiana Hoosier Care Connect

Lists services and codes that require prior authorization for participating UnitedHealthcare Community Plan of Indiana providers and explains how to submit authorization requests. Affects providers delivering inpatient and outpatient services to Hoosier Care Connect members in Indiana.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com using One Healthcare ID) or by phone at 877-610-9785.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplecodes listed that require prior authorization

phone & onlineauthorized submission methods provided

emergency/urgent careprior authorization not required for

pre-sequencing notificationBRCA testing requirement

Aucatzyl Apr 1, 2025

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.

new items with effective dates

Services and Codes Requiring Prior Authorization

Prior authorization criteria by service category

Services and codes that require prior authorization for Hoosier Care Connect members include, but are not limited to, the following categories and codes.

ALL of the following

CPT/HCPCS codes: 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 44799, 44705

Behavioral health: Prior authorization required; for specific prior authorization/referral instructions call the number on the member's health plan ID card.

ALL of the following

CPT/HCPCS codes: 69930, L8615, L8616, L8617, L8618, L8619, L8627, L8628

ALL of the following

Sample HCPCS/DME codes: A9279, E0265, E0266, E0270, E0274, E0277, E0296, E0297, E0300, E0302, E0304, E0328, E0329, E0439
Enteral services: Prior authorization required; enteral HCPCS examples listed

Prior authorization criteria (excerpt)

Prior authorization or notification requirements for specified services and codes.

ALL of the following

Enteral HCPCS examples provided in the list (see enteral codes in source).

ALL of the following

BRCA testing: notification/prior authorization is required before DNA sequencing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.
Sample CPT codes listed: 81161, 81298, 81292, 81293, 81294, 81295, 81296, 81297 (and additional genetic/molecular CPT codes enumerated in the genetic testing section).

ALL of the following

Sample home health codes: GO152, GO153

Prior authorization criteria by service category

Services and codes listed require prior authorization as specified below.

ALL of the following

Sample codes from list: Q5104, Q5123, J9312, J9311, J1412, J1449, J0596, Q5119, J2998, J9333, J2353, J0491, Q9998, J2502, J1602, J2327, J7320, J1299, J1930, J1747
Additional injectable codes include J3358, Q5127, Q9991, Q9992, J9226, J2781, 90378, J3241, J2356, Q5133, J3315, J1628, J3316, Q5115, Q5135, J9381, J1303, and others. Effective Oct 1, 2024: Q5133 and Q5135 require prior authorization. For unclassified codes J3490 and J3590, authorization is required only for a specified list of drugs (Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, Vabysmo).

ALL of the following

Examples: prostate procedures (52441, 52442), advanced outpatient imaging (selected CT/MRI/MRA/PET codes), remote patient monitoring (98975, 98976, 98980), rhinoplasty (30400, 30410, 30450, 30420), speech therapy and stimulators as listed.

ALL of the following

Codes and Coding Rules

Selected CPT/HCPCS codes requiring prior authorizationCPT | HCPCSCovered

43644	Bariatric procedure code listed for prior authorization
43770	Bariatric procedure code listed for prior authorization
81162	BRCA testing code listed for prior authorization
19316	Breast reconstruction code listed for prior authorization

Selected DME/HCPCS/K-codesHCPCS | Revenue | mixedCovered

E0439	DME code listed for prior authorization
E0442	DME code listed for prior authorization
K0108	DME/replacement mapping entry listed

General listed codes (fragmented)mixed

E2621	Referenced HCPCS/CPT code entry in list
E8O00	Referenced HCPCS/CPT code entry in list

Genetic testing codesCPTCovered

81161	Genetic testing code listed
81298	BRCA/genetic test code listed

Injectable medication J-/Q-codes (sample)HCPCSCovered

J3262	Actemra
J0801	Acthar
J0172	Aduhelm
J1552	Alyglo

Selected injectable medication HCPCS/CPT codesHCPCSCovered

Q5104	Renflexis
Q5123	Riabni
J9312	Rituxan
J9311	Rituxan Hycela
J1412	Roctavian
Q5133	Tofidence (subject to prior authorization effective Oct 1, 2024)
Q5135	Tyenne (subject to prior authorization effective Oct 1, 2024)

Transplant-specific additionsmixedCovered

Aucatzyl

Transplant-related product requiring prior authorization effective April 1, 2025 (named in transplants section)

DME retail purchase or cumulative rental cost threshold

Threshold amount$500 retail purchase or cumulative rental cost

Applies toDurable medical equipment (DME) codes listed in the policy

Authorization triggerRetail purchase or cumulative rental cost greater than $500 requires prior authorization

Exceptions/notesProsthetics are specifically noted as not considered DME for this threshold

Orthotics/prosthetics retail/rental cost threshold

How Providers Submit Requests and Operational Rules

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com; sign in with One Healthcare ID) or by phone at 877-610-9785. Out-of-network requests must be submitted by the out-of-network process (see portal/phone options).

Prior Authorization

Emergency/urgent care exception

Prior authorization is not required for emergency or urgent care services.

Prior Authorization

Services requiring prior authorization (examples)

Numerous specific services require prior authorization, including bariatric surgery, behavioral health referrals, cochlear implants and other auditory devices, and various reconstructive/cosmetic procedures; providers should check the listed CPT/HCPCS codes for each category.

Key Terms and Thresholds

Prior authorization overview

DefinitionPrior authorization is the required approval process for certain services before they are provided

Emergency/urgent carePrior authorization is not required for emergency or urgent care

Submission methodsRequests may be submitted online via the UnitedHealthcare Provider Portal or by phone at 877-610-9785

ScopeApplies to participating UnitedHealthcare Community Plan of Indiana providers for listed inpatient and outpatient services

DME codes requiring prior authorization when cost threshold exceeded

RequirementPrior authorization required when DME retail purchase or cumulative rental cost exceeds $500

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Indiana Hoosier Care Connect

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com using One Healthcare ID) or by phone at 877-610-9785.

SourceLink

On This Page

ALL of the following

Sample CPT codes listed: 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292, 58294, 59897, 58548

ALL of the following

Examples (not exhaustive)
- J3262 (Actemra), J0801 (Acthar), J0172 (Aduhelm), J1449 (Rolvedon), J0596 (Ruconest)
- Q5104 (Renflexis), Q5123 (Riabni), J9312 (Rituxan), J9311 (Rituxan Hycela), J1412 (Roctavian)
- Additional listed codes include J3358, Q5127, Q9991, Q9992, J9226, J2781, 90378, J3241, J2356, Q5133, J3315, J1628, J3316, Q5115, Q5135, J9381, J1303, J3490, J3590, J1823, J9376, J1322, J3032, J9332, J9334, Q5138

Examples: transplant-related products (Aucatzyl effective April 1, 2025 require prior authorization); urine drug testing (G0482, G0483); ventricular assist devices (33927, 33928, 33929, Q0507) — for VADs call the number on the member ID and fax to the Optum VAD Case Management team (fax 855-282-8929).
Wound vacs: E2402 — prior authorization required.

Threshold amount$500 retail purchase or cumulative rental cost

Applies toOrthotics and prosthetics codes listed in the policy

Authorization triggerRetail purchase or cumulative rental cost of more than $500 requires prior authorization

ExceptionPolicy text notes prosthetics are not DME (see related DME guidance)

Bariatric procedures (example CPT: 43644, 43770, 43843, 44705) — Center of Excellence requirement noted for some coverage.
Behavioral health — refer to the number on the member's ID card for mental health/substance use service referrals.
Cochlear implants and auditory devices (example codes: 69930, L8615-L8628).
Cosmetic and reconstructive procedures — many CPT codes listed requiring authorization.

Billing Rule

DME prior authorization rules

DME listed in this policy requires prior authorization when the retail purchase or cumulative rental cost exceeds $500; prosthetics are not considered DME and orthotics/prosthetics follow their separate threshold rules.

Examples of DME codes listed: A9279, E0265, E0266, E0270, E0274, E0277, E0296, E0297, E0300, E0302, E0304, E0328, E0329, E0439.
Authorization required only for DME codes listed with retail purchase or cumulative rental cost of more than $500.

Prior Authorization

Enteral services prior authorization

Enteral services require prior authorization; listed HCPCS entries for enteral supplies and formulas are subject to authorization per the policy.

Enteral HCPCS examples referenced in the policy (listed as B41xx entries).
Providers must obtain prior authorization for enteral services before provision.

Prior Authorization

Genetic testing prior authorization/notification

Genetic and molecular testing requires prior authorization/notification under the Genetic and Molecular Testing Prior Authorization/Notification Program; BRCA testing specifically requires notification/prior authorization before DNA sequencing and the ordering provider must notify the laboratory (the lab will notify UnitedHealthcare).

BRCA and many genetic test CPT codes (e.g., 81298, 81299, 81300–81319, 81321–81323, 81328, 81330, etc.) are included and require notification/prior authorization.
Ordering provider responsibility: notify the laboratory prior to DNA sequencing; the laboratory will notify UnitedHealthcare per the program.

Prior Authorization

Home health prior authorization

Home health services require prior authorization; listed home health codes (GO152, GO153) are subject to authorization.

Obtain prior authorization before initiating home health services associated with the listed codes.

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures require prior authorization for the CPT/HCPCS codes listed in the policy; obtain authorization prior to scheduling these procedures.

Examples of listed hysterectomy CPT codes requiring authorization: 51925, 58152, 58200, 58210, 58240, 58263, 58267, 58270, 58275, 58280, 58285, 58292, 58294, 59897, 58548.

Prior Authorization

Injectable medications prior authorization

Many injectable medications require prior authorization; providers must request authorization for the drugs and HCPCS/J-codes listed in the injectable medications sections before administration.

Examples of injectable J-/Q-codes included: J0597, J1556, J0585, J0567, J2329, J1786, J3111, J0180, J9155, J1572, J2182, J2350, J0222, J0129, J1576, J0897, J0802, J1745.

Prior Authorization

Injectable medications requiring prior authorization

Prior authorization is required for the specific injectable medications listed in the policy (selected sample codes appear in the list); providers must obtain authorization for these named HCPCS/CPT codes prior to provision.

Selected listed injectable codes include Q5104 (Renflexis), Q5123 (Riabni), J9312 (Rituxan), J9311 (Rituxan Hycela), J1412 (Roctavian), Q5133 (Tofidence — subject to PA effective Oct 1, 2024), Q5135 (Tyenne — subject to PA effective Oct 1, 2024).

Prior Authorization

Additional injectable medications and temporary/unclassified codes

Additional injectable medications, including those represented by temporary or unclassified codes, require prior authorization; note that Q5133 and Q5135 became subject to prior authorization effective Oct. 1, 2024.

Additional listed codes include J3358, Q5127, Q9991/Q9992, J9226, J2781, 90378, J3241, J2356, J9381, J1303, J3490, J3590, J1823, J9376, J1322, J3032, J9332, J9334, Q5138.
Effective Oct. 1, 2024: prior authorization required for Q5133 and Q5135.

Documentation Required

Authorization for unclassified/temporary drug codes

For unclassified/temporary HCPCS codes J3490 and J3590, authorization is required only when billing for a specified list of drugs (Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, Vabysmo); obtain prior authorization for those drugs under J3490/J3590 before administration.

Specified drugs requiring authorization when billed under J3490/J3590: Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, Vabysmo.

Billing Rule

Therapies, transports, orthotics/prosthetics prior authorization

Prior authorization is required for non-emergent air ambulance transport, a wide range of occupational and physical therapy codes, and orthotics/prosthetics codes listed; orthotics/prosthetics require authorization when retail purchase or cumulative rental cost exceeds $500.

Non-emergent air ambulance: A0430, A0431.
Therapy examples: 97012, 97016, 97110, 97112, 97113, 97530, 97760, G0281–G0283.
Orthotics/prosthetics examples: L3215, L3216, L3217, L3219, L3221, L3222, L3250, L3251, L3252, L3649, L8659 — authorization required for retail purchase or cumulative rental cost > $500.

Prior Authorization

Clinical procedures and imaging prior authorization

Certain clinical procedures and advanced outpatient imaging require prior authorization; providers ordering advanced outpatient imaging are responsible for providing notification prior to scheduling.

Prostate procedures example codes: 52441, 52442 require authorization.
Advanced outpatient imaging (CT/MRI/MRA/PET) requires notification prior to scheduling.
Other listed procedures needing authorization include remote patient monitoring (98975–98980) and certain stimulators (61863–61868).

Prior Authorization

Transplants, device therapies, testing prior authorization and contact instructions

Transplants, CAR T‑cell therapies and related services require prior authorization; for transplant and CAR T‑cell therapy services (including Carvykti, Kymriah, Yescarta) contact Optum at 888-936-7246. Ventricular assist devices require prior authorization and the VAD process includes calling the number on the member's ID card and faxing the nurse-provided form to the Optum VAD Case Management team at 855-282-8929.

Contact Optum at 888-936-7246 for transplant and CAR T‑cell therapy authorization.
Effective April 1, 2025: Aucatzyl requires prior authorization (listed under transplants).
VAD authorization instructions: call the number on the member's ID card and fax the form to Optum VAD Case Management at 855-282-8929.

Applies to listed DME codesExamples include E0439, E0265, E0266, E0270, E0274, E0277, E0296, E0297, E0300, E0302, E0304, E0328, E0329

Prosthetics noteProsthetics are explicitly noted as not DME (separate handling)

Injectable medications

DefinitionInjectable medications — drugs administered intravenously, by infusion, intramuscularly, subcutaneously or by injection — require prior authorization

ScopeExtensive list of J-/Q-/G- HCPCS codes in the policy require prior authorization (selected examples across chunks)

Unclassified codesFor J3490 and J3590, authorization is required only for a specified list of named drugs (see policy list)

BRCA testing (genetic)

RequirementBRCA testing requires notification/prior authorization before DNA sequencing is performed

ProcessThe ordering health care professional must notify the laboratory conducting the test (lab will notify UnitedHealthcare)

Covered codesMultiple BRCA/genetic CPT codes listed (examples include 81298, 81310, 81315, etc.)

J3490 / J3590 (unclassified drug codes)

CodesJ3490 and J3590 (unclassified/temporary drug codes)

Authorization ruleAuthorization required only for a specified list of drugs (Casgevy, Lantidra, Lyfgenia, Nulibry, Revcovi, Rivflosa, Ryplazim, Scenesse, Uplizna, Vabysmo)

Effective changesPolicy notes other code-specific PA changes (see injectable meds section for Oct. 1, 2024 updates)

Ventricular assist devices (VAD)

DeviceVentricular assist devices (VAD) — mechanical pumps that take over function of damaged ventricle

Authorization instructionCall the number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929

Prior authorizationPrior authorization is required for VADs (codes 33927-33929, Q0507 referenced in transplants/devices section)