Prior authorization and notification requirements for Preferred Care Network and Preferred Care Partners (Florida)
Defines prior authorization and notification requirements and submission methods for participating Preferred Care Network and Preferred Care Partners of Florida; affects in-network providers serving members of listed Medicare and HMO plans and specified WellMed groups.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization or Notification
Prior authorization criteria and exceptions
Prior authorization is required for specified services and codes except for emergency or urgent care; submission methods and exceptions are noted below.
ALL of the following
Submission method
- Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com).
- Or call: Preferred Care Network: 866-273-9444; Preferred Care Partners: 800-995-0480.
- WellMed groups must submit via the WellMed provider portal (eprg.wellmed.net) or by calling 877-299-7213.
- Prior authorization is not required for emergency or urgent care.
Cancer supportive care drugs
- Outpatient administration of colony-stimulating factors, erythropoiesis‑stimulating agents, antiemetics and certain bone‑modifying agents requires prior authorization for a cancer diagnosis.
- When a member’s plan ID card indicates 'Referral Required', a referral from the primary care provider and prior authorization may be required; follow the plan’s referral process as applicable.
Authorization/notification requirements (partial list)
Items listed below require either prior authorization or advance notification before services are provided or billed to UnitedHealthcare.
ANY of the following
- Cartilage implants — prior authorization required.
Prior authorization/notification listing
Items requiring prior authorization or notification include (non‑exhaustive): injectable medications (branded and J‑codes), immune globulins, IV iron products, gene and cellular therapies, and other listed drugs and services.
ANY of the following
- Selected injectable medications and specialty drugs — prior authorization required as noted (examples: Adakveo J0791; Aduhelm J0172; various branded and J‑coded agents listed in the injectable medications sections).
- Immune globulins (IVIG/SCIG) and related HCPCS/J codes — prior authorization/notification required per listing.
- Some drugs are included in specialty programs (Part B Step Therapy, etc.); follow the portal submission instructions for specialty pharmacy prior authorization.
Notification and prior authorization criteria (partial)
Services and settings that require notification or prior authorization (partial list):
ALL of the following
- Admission notification and/or prior authorization is required for inpatient/postacute admissions including acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals and skilled nursing facilities; use the Provider Portal or call the prior authorization phone number to submit.
Specialty drugs and selected HCPCS/J codes
- Certain specialty injectable and infusible drugs (listed J‑codes and Q‑codes) require prior authorization; submit via the Prior Authorization and Notification tool or call the specialty pharmacy number (for example, 888‑397‑8129 for Specialty Pharmacy submissions).
Procedures and therapies
- Orthognathic surgery, spine and joint surgeries, pain management procedures and select potentially unproven/experimental services require prior authorization or notification as specified; refer to the listed CPT/HCPCS codes (examples provided in the procedures section).
- Physical therapy and occupational therapy provided at home or on an ambulatory basis — direct requests to a health plan contracted vendor; call the number on the member's health plan ID card.
Authorization requirements (partial)
The categories below require either notification or prior authorization; specific codes and instructions are provided in each category.
ALL of the following
Prior authorization required for listed categories
- Organ/tissue transplant and transplant‑related services, including cellular and gene therapy — prior authorization required and should be directed to a health plan contracted vendor; contact the number on the member's ID card for vendor routing.
- Vein procedures (e.g., saphenous vein removal/ablation) — prior authorization required.
Exceptions / code‑level notes
- Some radiation therapy prior authorization requirements have code‑specific exceptions (for example, IGRT noted as no longer requiring prior authorization in one entry); verify authorization need at the code level.
CPT/HCPCS/ICD-10 Codes Referenced
| J2506 | Pegfilgrastim (Neulasta) - requires prior authorization for outpatient cancer diagnosis |
| J1447 | Tbo-filgrastim (Granix) - requires prior authorization |
| J1456 | Antiemetic drugs - listed as requiring prior authorization |
| J0885 | Erythropoiesis-stimulating agents - prior authorization required |
| J0897 | Denosumab (Prolia/Xgeva) - bone-modifying agent requiring prior authorization |
| Q5108 | Pegfilgrastim biosimilar - prior authorization note |
| 37220 | Endovascular revascularization, initial peripheral |
| 37224 | Transcatheter therapy, peripheral artery |
| 37230 | Transcatheter therapy, other peripheral vascular |
| C50.011 | Malignant neoplasm of nipple and areola, right female breast |
| Z90.10 | Acquired absence of breast and nipple |
| I70.* | Multiple I70.x peripheral vascular disease codes listed |
| M86.* | Multiple M86.x osteomyelitis codes listed |
| J1745 | Listed injectable drug HCPCS |
| J1437 | Intravenous iron product / HCPCS entry |
| J1439 | Intravenous iron product / HCPCS entry |
| J2782 | HCPCS entry referenced |
| J2507 | Krystexxa (HCPCS) referenced |
| J1306 | Leqvio / HCPCS referenced |
| J0175 | HCPCS entry referenced |
| J0174 | Leqembi / HCPCS referenced |
| J9311 | Rituximab / HCPCS referenced |
| J1747 | Spevigo / HCPCS referenced |
| 21120 | Orthognathic surgery code |
| 22100 | Spine surgery code (example) |
| 22554 | Spine surgery code (example) |
| 27447 | Knee procedure code |
| 29866 | Arthroscopy/shoulder procedure code |
| 63030 | Spinal procedure code |
| 0200T | Category III code listed |
| J7330 | Implantable device HCPCS listed |
| 62350 | Pain management injection code |
| 28890 | Potentially unproven services code example |
How to Submit Requests and Operational Requirements
How to submit prior authorization requests
Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (sign in at UHCprovider.com and select the Prior Authorization and Notification tab) or by phone: Preferred Care Network 866-273-9444 or Preferred Care Partners 800-995-0480. Prior authorization is not required for emergency or urgent care.
- Online: UHCprovider.com -> Sign In -> Prior Authorization and Notification tab
- Phone: Preferred Care Network 866-273-9444; Preferred Care Partners 800-995-0480
- Emergency or urgent care: prior authorization not required
WellMed submission instructions
WellMed groups must submit prior authorization requests via the WellMed provider portal at eprg.wellmed.net or by calling 877-299-7213, 8 a.m.–5 p.m. ET, Monday–Friday.
- Portal: eprg.wellmed.net
- Phone: 877-299-7213 (8 a.m.–5 p.m. ET, Monday–Friday)
Behavioral health prior authorization routing
For behavioral health services and specific behavioral-health codes, call the number on the member's health plan ID card for referral and prior authorization instructions.
- Many plans provide coverage only through a designated behavioral health network
- Use the phone number on the member's ID card for code-specific authorization/routing
How to obtain prior authorization/notification
Submit prior authorization and notification requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or by calling the prior authorization phone number provided in the document (888-397-xxxx).
- Portal: UHCprovider.com -> Prior Authorization and Notification tab
- Alternate: phone number shown for prior authorization/notification (document lists 888-397-xxxx)
Cartilage implants — prior authorization required
Cartilage implant procedures require prior authorization before services are provided.
Injectable chemotherapy — notification required
Injectable chemotherapy (J9000–J9999 and specified J-codes such as J0640, J0641, J0642, Q-codes and miscellaneous HCPCS) require notification; providers are instructed to submit prior authorization requests online using the Prior Authorization and Notification tool.
Cochlear implants and auditory implants — prior authorization
Prior authorization is required for cochlear and other auditory implants; requests should be submitted through the UnitedHealthcare Provider Portal or by calling the listed prior authorization phone number.
- Use UHCprovider.com Prior Authorization and Notification tab or call the prior authorization phone number
Cosmetic procedures and ESRD/dialysis — notification rules
Advance notification is required for inpatient or outpatient cosmetic procedures that change or improve speech or appearance, and advance notification is required if a member is referred to an out-of-network dialysis provider; advance notification is not required for ESRD when a Medicare member travels outside the service area.
- Cosmetic/reconstructive procedures that modify speech or appearance: advance notification required
- Out-of-network dialysis referrals: advance notification required
- ESRD travel: advance notification not required for Medicare members traveling outside service area
Home health services — state-specific prior authorization
Prior authorization for home health services is required only for members residing in and receiving services in Alabama and Georgia; direct requests to the health plan contracted vendor and use the phone number on the member's ID card for details.
- States requiring home health prior authorization: Alabama and Georgia
- All requests should be directed to a health plan contracted vendor; call number on member's ID card
Injectable medications — prior authorization/notification
Many injectable medications (branded products and specific J-codes) are listed as requiring prior authorization or notification; providers should use the UnitedHealthcare Provider Portal or call the specified phone number to obtain authorization.
- Examples of listed products and J-codes appear in the injectable medications section (see document for specific codes)
- Submit prior authorization via UHCprovider.com or call the prior authorization number
Prior authorization submission (specialty pharmacy and postacute admissions)
To submit specialty pharmacy prior authorizations or prior authorization for post-acute admissions, use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (select Specialty Pharmacy) or call 888-397-8129; naviHealth manages in-scope postacute prior authorizations (Phone: 855-851-1127; Fax: 844-244-9482).
- Portal: UHCprovider.com -> Create a new authorization submission -> select Specialty Pharmacy
- Phone: 888-397-8129
- naviHealth (postacute manager): Phone 855-851-1127; Fax 844-244-9482
Admission notification requirement
Notification (and prior authorization of the admission date) is required for inpatient and postacute admissions including acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals and skilled nursing facilities; certain plans are excluded from the SNF prior authorization requirement as noted in the document.
- Settings requiring notification: acute care hospitals, AIR, critical access hospitals, LTAC, SNF
- Some plans (e.g., UnitedHealthcare Assisted Living Plans, UnitedHealthcare Nursing Home plan) are excluded from SNF prior authorization requirement
Out-of-network referral notification
Advance notification is required when a network provider directs a Preferred Care Network or Preferred Care Partners member to an out-of-network facility, physician or other care provider (when the member's benefits do not include out-of-network coverage) or when requesting in-network cost sharing due to no available in-network providers.
- Use advance notification to request in-network cost sharing or benefit levels if no in-network provider is available
- Advance notification required when directing member to out-of-network provider and benefits lack out-of-network coverage
Prior authorization / Notification required for assorted services
Potentially unproven, experimental, investigational or linked services and certain procedures (examples listed in the document) require prior authorization; physical and occupational therapy provided at home or on an ambulatory basis must be directed to a health plan contracted vendor for authorization.
Radiation and prostate procedures — prior authorization
Prior authorization is required for prostate procedures and many radiation therapy modalities (including proton beam therapy: CPT 77520, 77522, 77523, 77525); note that prior authorization is no longer required for certain radiation therapy entries such as Image Guided Radiation Therapy (IGRT) per the document.
ENT / Sleep apnea / Spinal / Stimulators — prior authorization
Prior authorization is required for listed ENT, sleep apnea, spinal surgeries and implantable stimulators; examples include rhinoplasty for functional impairment (CPTs 30400–30465), sleep apnea procedure codes (e.g., 21685, 42145), spinal surgery and stimulator device codes (E0747–E0760).
Transplant and cellular/gene therapy — prior authorization
Organ and tissue transplants and transplant-related services (including cellular and gene therapy) require prior authorization and should be directed to a health plan contracted vendor; several transplant-specific CPT/HCPCS codes and cell/gene therapy products are listed in the document.
- Transplant and related CPT/HCPCS examples listed (see document for full code list)
- Cellular and gene therapy services (e.g., Abecma, Breyanzi, Carvykti) must be directed to a contracted vendor for prior authorization
VAD — prior notification and coordination
Ventricular assist devices (VAD) require prior notification and coordination via Optum VAD Case Management; call 888-936-7246 or the notification number on the member's health plan ID card.
- Call Optum VAD Case Management at 888-936-7246
- Or use the notification number on the back of the member's health plan ID card
Terminology and Key Fields
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