Submit prior authorizations via UHC Provider Portal

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Sign in with your One Healthcare ID, select the Prior Authorization and Notification tab, and follow the portal workflow. Prior authorization is not required for emergency or urgent care; member-specific benefit plans and site-of-service reviews must be referenced when deciding coverage.

Services flagged as requiring prior authorization

Many surgical categories list 'Prior authorization required' for the CPT/HCPCS codes shown in the document (examples include arthroplasty, arthroscopy, bariatric surgery, and breast reconstruction [non-mastectomy]). Providers must check the listed codes and obtain authorization before scheduling elective services.

Prior authorization required for non-mastectomy breast reconstruction

Prior authorization is required for breast reconstruction (non-mastectomy) when billed with the listed diagnosis codes; obtain authorization per the portal instructions provided in this document.

• See listed ICD-10 diagnosis codes (e.g., C50.021, C50.022, C50.121, etc.) in the breast reconstruction section for which prior authorization is required.

Breast reconstruction (non-mastectomy) — PA required for listed ICD-10 codes

Prior authorization is required for breast reconstruction (non-mastectomy) associated with the listed diagnosis codes; providers must submit requests using the portal process described in this document.

• Diagnosis codes include multiple C50.* codes (see breast reconstruction entries) that trigger the prior authorization requirement.

PA required — outpatient colony‑stimulating factors and bone‑modifying agents

Prior authorization is required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis; many specific J‑ and Q‑codes are listed and require authorization (some codes also require PA when used for non-oncology diagnoses).

• Examples of listed codes: J1442, J1447, J2506, Q5101, Q5110, Q5111, Q5120, Q5122, J0897 (and many others in the injectables/CSF lists).
• Certain codes identified with an asterisk require prior authorization for non-oncology diagnoses as noted in the injectables section.

Cardiology outpatient/office procedures — notify or obtain PA before performance

Notification or prior authorization is required for participating physicians before performing listed outpatient and office-based cardiology procedures (diagnostic catheterizations, electrophysiology implants, echocardiograms, stress echocardiograms).

• Examples of listed cardiology codes: 33206–33229 series, 93306–93319, 93454–93461, 0571T, 0614T.
• Submit notification/prior authorization requests via the UnitedHealthcare Provider Portal or call 866-889-8054.

How to obtain notification/prior authorization

For notification or prior authorization requests, submit online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054 as applicable for the service.

Cardiovascular procedures — prior authorization required

Cardiovascular services require prior authorization where indicated; providers must review the cardiovascular entries and obtain authorizations for the listed procedures before providing elective services.

Exceptions and age‑based prior authorization limits — check code notes

Some CPT/HCPCS entries include exceptions or age-based limits; notes state '*Prior authorization is not required for these diagnosis codes.' and '**Prior authorization required for members ages 18 and older.' Review code-level notes for exemptions and age restrictions.

• Check code-specific additional information fields for notes on exemptions and age-based prior authorization requirements.

PA and site‑of‑service review — may apply (TX exception noted)

Prior authorization is required and site-of-service review may apply for services listed in this document; site-of-service review is noted to apply for all states except Texas for certain entries.

• Site-of-service review may be performed as part of prior authorization for indicated codes; verify state-specific rules in the listing.

Listed CPT/HCPCS codes — prior authorization required (see code lists)

Specific CPT/HCPCS codes throughout the document are explicitly marked 'Prior authorization required' (examples include cartilage implants, inpatient video EEG, certain chemotherapy and injectables); providers must obtain authorization for those codes before services are rendered.

• Examples: cartilage implant codes 27412/29867/27415/29868; numerous J‑codes for chemotherapy/CSF referenced in the injectables lists.
• Refer to the code listings in the document for the full set of codes requiring prior authorization.

Clinical trials — prior authorization required

Prior authorization is required for procedures billed for clinical trials; the document lists procedure codes (e.g., G0276, S9988, G0293, S9990, G0294, G2000) that require authorization prior to billing.

Cochlear and auditory implants — PA required for listed codes

Prior authorization is required for cochlear and other auditory implants; the document lists specific CPT/HCPCS codes (e.g., 69717, 69930, L8617–L8628, V5273) that require authorization.

Continuous glucose monitoring — PA for type 2 and gestational diabetes

Continuous glucose monitoring devices require prior authorization when used for type 2 or gestational diabetes; prior authorization is not required for type 1 diabetes per the document.

• Example codes: A4226, A4238, A4239, A9276; diabetes diagnosis codes referenced in the CGM section guide the PA requirement.

DME — prior authorization required for listed HCPCS E‑codes

Durable medical equipment (DME) items listed (HCPCS E‑codes and others) require prior authorization; prosthetics are noted as not categorized as DME and have separate listings.

• Sample E-codes requiring PA include E0147, E0193, E0194, E0265, E0266, E0277, E0296, E0297, E0300, E0302.

DME HCPCS E‑codes — PA required (listed entries)

Prior authorization is required for the listed HCPCS E‑codes for DME noted in the document; follow portal submission instructions to obtain authorization for these items.

Foot surgery — PA required; site‑of‑service review may apply (state exceptions)

Foot surgery CPT codes listed require prior authorization; site-of-service review may apply for the listed codes except in Texas and Wisconsin where site-of-service review exclusions are noted while PA still applies.

• Examples include 33477, 36514, 64722, 95965–95967, and FESS-related codes; check the foot surgery section for full code list and state exceptions.

FESS procedures — PA required for listed CPTs

Functional endoscopic sinus surgery (FESS) CPT codes listed require prior authorization for some items; providers should obtain PA for the enumerated CPT codes before scheduling.

• Examples include 28285, 28295, 28299, 31240, 31256–31257, 31254–31255, 31276, 31287–31288, 31267.

Gender dysphoria treatments — notification/PA required with F64.x or Z87.890

Notification or prior authorization is required for gender dysphoria–related procedures when submitted with diagnosis codes F64.x or Z87.890; providers must submit requests for the listed CPT codes per the document.

• Example CPTs include 11980, 14000–14041, 15734–15758, 19303, 54125, 56800, and others shown in the gender dysphoria sections.

Gender dysphoria — PA/notification required (check state exclusions)

Notification or prior authorization is required for gender dysphoria–related procedure codes submitted with diagnosis codes F64.x or Z87.890; review state-specific exclusions noted in the listing.

Genetic/molecular testing (BRCA) — PA/notification required; ordering provider must supply lab and test name

Genetic and molecular testing, including BRCA testing performed in an outpatient setting, requires prior authorization/notification; the ordering provider must indicate the laboratory and test name and payment is authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program.

• Example CPT codes: 81162, 81163, 81164, 81403, 81412, 81415, 81426, 81435, 81450–81464 (see genetic testing section).
• Notification/prior authorization is required before DNA sequencing for BRCA testing.

Home health — PA varies by plan; check member benefit document

Home health prior authorization requirements vary by member benefit plan; providers must reference the member-specific benefit plan document and the CPT/HCPCS codes listed to determine coverage and any PA requirements.

• Examples of home health codes shown include G0156, T1001, S9341, G0160, G0159, S9122, T1004.

Hysterectomy — prior authorization required for listed codes

Hysterectomy procedures require prior authorization for the CPT codes listed in the document; obtain PA before scheduling these surgeries.

• Examples: 58150, 58262, 58291, 58542, 58152, 58267, 58292, 58543, 58544, 58541, 58552, 58553, 58554, 58570.

IMRT — PA required (codes 77385, 77386, G6015, G6016)

Intensity-modulated radiation therapy (IMRT) requires prior authorization; listed codes include 77385, 77386, G6015, and G6016 and must be authorized before treatment.

Infertility services — PA required (state exclusions noted)

Infertility diagnostic and treatment services require prior authorization for the listed codes in all states, with specific state exclusions noted for certain codes; providers must obtain PA per the listing before providing services.

• Examples: 58760, 89260, 89261 and others noted; NM, SC and WI exclusions and additional exclusions for IA, IN, NE, WY for some codes are specified.

Injectables — prior authorization required for listed J/Q codes

Injectable medications across multiple therapeutic areas are subject to prior authorization; many J‑codes and Q‑codes are listed (examples provided) and require PA or predetermination as indicated.

• Examples include J0896, J1437, J1439, J1304, J1426, J1442, J1447, J1449, J2506, Q5101, Q5122, and numerous others in the injectables lists.

Unclassified J‑codes (J3490/J3590) — portal submission required

For unclassified injectable codes J3490 and J3590, notification/prior authorization is required and prior authorization requests must be submitted online using the Prior Auth Provider Portal at UHCprovider.com (Sign In).

• The portal is the only channel available for PA submission of unclassified J‑codes per the document.

Listed injectables — PA applies to enumerated J/Q codes

The document includes numerous specific HCPCS/J‑ and Q‑codes for injectables that are subject to prior authorization; providers must refer to the listed codes and obtain authorization as instructed.

• Examples: J1442 (Neupogen), J1447 (Granix), J1449 (Rolvedon), J2506 (Neulasta), Q5101 (Zarxio), Q5108 (Fulphila), Q5110 (Nivestym), Q5122 (Nyvepria).

Prior authorization instruction for unclassified J‑codes (J3490/J3590)

For unclassified codes J3490 and J3590, notification/prior authorization is required and prior authorization requests must be submitted online using the Prior Auth Provider Portal at UHCprovider.com (Sign In).

Injectable medication code lists — PA/predetermination process applies

The document enumerates many J‑ and HCPCS codes for injectable medications; entries in those listings indicate the medications are subject to the prior authorization/predetermination process described.

Colony‑stimulating factor J‑codes — PA required (see 'how to obtain PA')

Multiple J‑codes for colony‑stimulating factors are listed with notes directing providers on how to obtain prior authorization; obtain PA for these codes before administration in outpatient settings for cancer supportive care.

• Sample entries include J1370, J1380, J1410, J1430, J1438, J1443, J1444, J1445, J1450, J1451 and many others across the CSF lists.

Injectable/predetermination codes — PA/predetermination applies

The injectables and predetermination section indicates listed medications require prior authorization or predetermination; providers should follow the portal instructions and the code-level notes for submission.

Additional injectable codes — PA reference present

Additional injectable J‑codes are listed throughout the document with prior authorization references; providers must obtain authorization for the listed injectable products per the portal process.

Injection arthrogram — PA required; site‑of‑service review applies (TX exception)

Injection arthrograms require prior authorization in all states; site‑of‑service will be reviewed as part of the prior authorization process for the listed codes except in Texas.

• Example code referenced: 27096; note that site‑of‑service review applies except in Texas.

Mastectomy and supplies — PA required; state exclusions noted

Prior authorization is required for mastectomy and for the listed medical and surgical supplies (A‑codes); mastectomy exclusions are specified for several states.

• Mastectomy code example: 19300; exclusions: Illinois, Louisiana, Michigan, North Carolina, Oklahoma, Tennessee, Texas, and Virginia.
• Medical/surgical supply examples: A4557, A6502, A6503, A6513, A4600.

Procedures and device implantation — PA required for listed codes

Prior authorization is required for specified medicine services/procedures (e.g., 96130–96139) and for orthognathic surgery and neurostimulator implantation codes listed; obtain PA before scheduling these procedures.

• Medicine services examples: 96130–96139.
• Orthognathic surgery examples: 21127, 21141–21156, 21193–21199 (see orthognathic section).

Extensive CSF (J‑code) listings — PA referenced across entries

The document provides an extensive list of colony‑stimulating factor HCPCS/J‑codes; many entries include 'how to obtain prior authorization' placeholders that indicate PA is required for those products.

Orthognathic surgery — PA required for listed CPTs

Multiple orthognathic surgery CPT codes are listed and the section includes 'Additional information = Prior authorization required.' Providers must obtain PA for the orthognathic CPTs enumerated.

Orthotics & prosthetics — PA required for listed HCPCS L‑codes

Extensive orthotics and prosthetics HCPCS L‑code listings are included and many entries reference how to obtain prior authorization; providers must seek PA for the listed orthotics/prosthetics codes.

• Sample L‑codes shown include L0112, L0220, L0484, L1840, L2034 and many more; check the orthotics/prosthetics section for the full list.

Pain injections and pain management — PA required for all states; site‑of‑service reviewed

Prior authorization is required for pain injections and many pain management CPT/HCPCS codes for all states; site‑of‑service will be reviewed as part of prior authorization and may apply except for Texas in some notes.

• Examples of pain injection codes: 62291, 62292, 64620, G0259, G0260; numerous additional pain management CPTs listed (e.g., 62320–62327, 64405, 64415, 64510, 64640).
• Site‑of‑service review may be performed during PA.

PA requirements and site‑of‑service review — colony‑stimulating factor and other codes

Prior authorization is required for the listed colony‑stimulating factor HCPCS L‑codes and other listed procedures; site‑of‑service review is noted for many listings and may affect authorization outcomes.

Flap repair (14020/14021/14061) — PA exception when billed with skin cancer (state‑limited)

Flap repair CPTs 14020, 14021, and 14061 are an exception: they will not require prior authorization when billed with skin cancer diagnoses, but this exception applies only to Florida, Illinois, Maryland, Michigan, Virginia and Washington.

• The flap repair exception is limited to the states listed and applies only when billed with skin cancer diagnosis codes.