CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements and submission methods — UnitedHealthcare Community Plan (Arizona)

Governs prior authorization requirements and submission methods for providers participating with UnitedHealthcare Community Plan of Arizona (ACC) Medicaid for specified inpatient and outpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements and submission methods — UnitedHealthcare Community Plan (Arizona)

Policy CodePolicy N/A

Change TypeAdministrative (no material changes)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or call 888-397-8129 / 800-445-1638.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PortalPortal submission

PhonePhone option

<21 rulePediatric EPSDT rule

J‑codesInjectable chemo PA

Preferred HomecareDME vendor

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.

Coverage Criteria and Rules

Coverage criteria and rules (partial)

General coverage notes and examples included in this portion of the document.

Services must be covered benefits as defined by the Arizona Health Care Cost Containment System (AHCCCS).

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

Experimental and investigational services are not covered benefits and require prior authorization when applicable for members younger than 21 (see EPSDT guidance).

All rendering providers, facilities and vendors must be actively registered with AHCCCS.

Services delivered inside multi‑specialty interdisciplinary clinics (MSIC) to CRS‑designated members do not require prior authorization.

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

Allergy immunotherapy (age‑based rule): For members younger than 21: allergy immunotherapy and allergy testing are covered under EPSDT when medically necessary; for members 21 and older allergy immunotherapy is not a covered benefit.

Chemotherapy prior authorization criteria

Prior authorization requirement for outpatient injectable chemotherapy:

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis.

Includes chemotherapy injectable drugs billed under J9000–J9999, leucovorin/levoleucovorin codes (J0640, J0641, J0642), Lupron Depot (J1950), Q‑coded chemotherapy injectables, and miscellaneous HCPCS billed chemo injectables without assigned codes.

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888‑397‑8129 for assistance.

EEG and seizure monitoring coverage

Neurodiagnostic monitoring and EEG coverage notes:

Prior authorization is required for specified cerebral seizure monitoring CPT codes (e.g., 95700, 95711–95713).

Outpatient EEG CPT codes listed that require prior authorization include 95720, 95722, 95724 and 95726.

Inpatient video seizure monitoring codes (95714–95718) are noted as prior authorization not required for inpatient video monitoring.

Prior authorization criteria and informational items

Prior authorization requirements and where to obtain further policy details:

For members younger than 21, prior authorization is required for all services considered experimental and/or investigational; refer to AMPM Chapter 300 Section 320 and Chapter 400 Section 430 for EPSDT guidance.

Functional endoscopic sinus surgery (FESS) codes listed (e.g., 31240, 31253–31259, 31267, 31276, 31287, 31288) require prior authorization for members younger than 21.

Enteral/parenteral nutrition and oral supplements for members younger than 21 must follow AMPM Chapter 400/Certificate of Medical Necessity guidance; to request services/supplies call Preferred Homecare at 800‑636‑2123.

Eye care benefits for members younger than 21 include routine annual exams, lenses and frame allowance; for members 21 and older prior authorization is required when medically necessary—contact Nationwide Vision at 480‑961‑1702.

Durable medical equipment items listed require prior authorization; some DME codes are subject to retail purchase or cumulative rental cost thresholds and may not be covered without PA.

Authorization stance for pediatric (<21) services

Summary of authorization stance for selected services for members younger than 21.

Hearing evaluations and hearing aid codes for members younger than 21 (e.g., 92590–92593 and related V‑codes) generally do not require prior authorization (noted: 'Prior authorization is not required').

Home health care services listed (for example G0299, G0300, S9123, S9124) require prior authorization for members younger than 21.

Infusion in‑home services and injectable medications not covered by the vendor require prior authorization; requests for infusion/in‑home supplies are handled by Optum Infusion at 888‑705‑4470.

Incontinence supplies for members younger than 21 are a benefit only when provided through Preferred Homecare; providers must contact Preferred Homecare to request supplies.

Specified hysterectomy and related procedure CPT codes for members younger than 21 are listed and require prior authorization for the codes shown.

Injectable medication prior auth code list

Code list for prior authorization of injectable drugs (section listing)

Sample injectable codes: J2350, J2267, J0222, J1576, J2353, J1930, J1745, J9312, Q5135, C9094, J3490, J3590, J1823

This is a non‑exhaustive list of injectable HCPCS/J‑codes appearing in the policy; additional J/Q/C and unclassified codes are listed elsewhere and may require prior authorization.

Prior authorization and notification criteria

Prior authorization/notification requirements and special rules

Prior authorization is required for listed injectable medication HCPCS/CPT codes (including Q5135, J9381, J1823, intravitreal VEGF J‑codes and many others); for unclassified/temporary codes (C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590) PA is required only for specified products (e.g., Nulibry, Revcovi, Rivfloza, Vabysmo).

Notification is required for inpatient admissions; prior authorization is required for specified inpatient facility services and some admissions per the policy.

Prior authorization is required for non‑emergent air ambulance and transport codes listed (e.g., A0430, A0431, A0435, A0436).

Orthotics and prosthetics L‑code items listed require prior authorization when cost/clinical criteria apply; some items are subject to age‑based rules and cost thresholds (for example, items with cost > $500 may trigger PA/retail limitations).

Service-specific PA criteria (excerpt)

Coverage and prior authorization rules by service category included in this section:

Outpatient therapy (occupational, physical, speech): prior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits; for members younger than 21 speech therapy is covered when medically necessary with no annual limits but requests are reviewed for medical necessity.

For members 21 and older outpatient speech therapy is not a covered benefit except for QMB members (speech therapy covered when medically necessary).

Advanced outpatient imaging (CT/MRI/MRA/PET/nuclear medicine): prior authorization required; submit requests via the Provider Portal or call 866‑889‑8054 and consult UHCprovider.com/AZcommunityplan for CPT lists.

Orthotics and prosthetics: prior authorization is required for all out‑of‑network services and for numerous L‑codes listed in the policy.

Service requests for physician‑administered drugs must include J‑codes and NDC codes; pharmacy PA contact is UnitedHealthcare Pharmacy Prior Authorization Service (phone 800‑310‑6826 or fax 866‑940‑7328) and PA forms are available on UHCprovider.com/AZcommunityplan.

Prior authorization rules and SOS exceptions

Prior authorization requirements and site‑of‑service exceptions

Sinuplasty codes (31295–31298) require prior authorization when requested in the settings specified in the policy.

Sleep apnea procedures and surgeries (for example CPT 21685, 41599, 42145) require prior authorization for the codes listed.

ASC exception: Site‑of‑service prior authorization is only required when the service is requested in an outpatient hospital setting; prior authorization is not required if performed at a participating ambulatory surgery center (ASC) for certain items.

Skilled nursing facility services require prior authorization.

Prior authorization coverage criteria (partial, codes listed)

Coverage stance is that many listed services require prior authorization; specific codes are enumerated and special processes apply for certain services.

Prior authorization is required for listed spinal surgery CPT codes (e.g., 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22210, 22212, 22214, 22510–22515 and others) as shown in the policy.

Transplant and CAR T‑cell therapy services require prior authorization/notification and case management coordination; contact the UnitedHealthcare Community and State Transplant Case Management Team at 800‑418‑4994 or the notification number on the member ID card.

Ventricular assist devices (VAD) require prior authorization/notification: call the notification number on the back of the member's health plan ID card and fax required forms to the Optum VAD Case Management Team at 855‑282‑8929.

Non‑emergent transportation (taxi and stretcher van) requires prior authorization; schedule transportation via Medical Transportation Management (MTM) at 888‑700‑6822.

Codes and Coding Guidance

Augmentative and alternative communication codesCPT | HCPCSCovered

92607	Augmentative and alternative communication
92608	Augmentative and alternative communication
92609	Augmentative and alternative communication
A9901	Augmentative and alternative communication
E2500	Augmentative and alternative communication

Examples: bariatric surgery and colony-stimulating factor codesCPT | HCPCSCovered

43644	Bariatric surgery
43645	Bariatric surgery
43770	Bariatric surgery
J1442	Filgrastim (Neupogen)
J2506	Pegfilgrastim (Neulasta)

Oncology supportive agents requiring prior authorizationHCPCSCovered

J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
J1448	Trilaciclib (Cosela)
J0897	Denosumab (Xgeva)
J1449	Colony stimulating factors (group)

Cardiovascular / vascular codes (many ICD/diagnosis codes also listed)CPT | ICD-10Covered

37220	Endovascular procedures (example cardiovascular)
37221	Endovascular procedures (example cardiovascular)
93580	Cardiology related procedure

Cardiovascular-related ICD-10 entriesICD-10

I70.541	Authorization and Notification Program entry
I70.542	Authorization and Notification Program entry
I70.543	Authorization and Notification Program entry
I70.544	Authorization and Notification Program entry
I70.545	Authorization and Notification Program entry
I70.548	Authorization and Notification Program entry
I70.549	Authorization and Notification Program entry

Musculoskeletal/infectious diagnosis ICD-10 entriesICD-10

M86.051	Osteomyelitis code listed for prior auth
M86.052	Osteomyelitis code listed for prior auth
M86.059	Osteomyelitis code listed for prior auth
M86.1	Osteomyelitis/general category entries

Representative CPT/HCPCS/J-code groups mentionedmixedCovered

95700	Cerebral seizure monitoring
95714	Inpatient video monitoring
95720	EEG outpatient
J9000-J9999	Chemotherapy injectable drug range
J0640	Leucovorin
J0641	Levoleucovorin

Selected DME HCPCS codesHCPCSCovered

E0265
E0266
E0270

Biomarker/genetic testing codes (members <21)CPTCovered

81313	Biomarker/genetic testing code
81327	Biomarker/genetic testing code
81435	Biomarker/genetic testing code

FAI procedure codes (members <21)CPTCovered

29914	Femoroacetabular impingement (FAI) code
29915	FAI code
29916	FAI code

Mixed laboratory / biomarker / cytogenetic codes (members <21)mixed

88263
88264
88267
88269
88271
88272
88273
88274
88275
88280

1–10 of 19

1/2

Injectable medication J-codes enumeratedHCPCS

J2508
J3380
J1302
J7204
J3111
J1305
J0177
J0517
J1951
Q0138

1–10 of 34

1/4

Repeated single-code groupHCPCSCovered

J2350

Octreotide acetate

Sample listed injectablesmixedCovered

J2267	Omvoh™
J1745	Remicade®
J1930	Somatuline® Depot
Q5135	Tzield™
C9094	C-series HCPCS example

Representative HCPCS/CPT codes in this sectionHCPCS | CPT | mixed

Q5135	Tzield™
J9381
J1823	Uplizna®
J0178	Intravitreal VEGF agent
A0430	Non-emergent air ambulance
L3901	Orthotic/prosthetic example

HCPCS L-code groupsHCPCS

L55xx-L67xx (multiple L-codes listed)

HCPCS L-codes associated with intravitreal VEGF and orthotics/prosthetics (numerous specific codes listed across chunks)

Therapy and surgical CPT codesCPT

97012, 97022, 97034, 97014, 97026, 97016, 97028	Outpatient therapy CPT codes
92507, 92508, 92526	Speech therapy CPT codes
29805-29828	Arthroscopic shoulder surgery CPT codes

J-codesHCPCS

J0224, J0717, J1290, J1300, J1303, J1427, J1428, J1429, J1786, J2326, J2357, J2840, J3060, J3385, J3398, J3399

Examples of J-codes referenced for pharmacy/physician-administered drugs

Sample listed CPT codes by specialtyCPT

66982	Cataract surgery
66984	Cataract surgery
43200	Esophagoscopy, diagnostic
43236	Esophagogastroduodenoscopy with biopsy
29835	Arthroscopy, shoulder with decompression
29879	Knee arthroscopy

Ophthalmologic codesCPT

65710	Corneal transplant (penetrating)
67036	Retinal photocoagulation
67228	Panretinal photocoagulation

Urologic/urinary system codes (examples)CPTCovered

52276	Listed urinary system/urologic procedure code
52287	Listed urinary system/urologic procedure code
52320	Listed urinary system/urologic procedure code

Spinal surgery codesCPTCovered

22100	Spinal surgery code
22514	Spinal surgery (noted with special SOS applicability)
63001	Spinal/neurosurgery code

Stimulators and implantable device codesmixedCovered

E0747	Bone growth stimulator
L8680	Neurostimulator/implantable device HCPCS examples
63650	Neurostimulator implantation CPT example

Wound vacHCPCSCovered

E2402

Wound vacuum device

Ventricular assist device (VAD) codesmixedCovered

33927	Ventricular assist device related CPT example
Q0507	VAD related HCPCS example

EPSDT age rule for allergy immunotherapy

RuleAllergy immunotherapy is covered for members younger than 21 under EPSDT when medically necessary; it is not a covered benefit for members 21 and older.

ScopeIncludes subcutaneous allergy shots, sublingual immunotherapy (SLIT) and other routes when provided to members <21 under EPSDT.

How Providers Should Request Authorization and Next Steps

Prior Authorization

How to request prior authorization

To request prior authorization, submit your request by one of the following methods: Online — use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (go to UHCprovider.com and click Sign In in the top-right corner to sign in with your One Healthcare ID and password). Phone — call the number shown for the specific service below (or general numbers 800-445-1638 or 888-397-8129 where noted).

Online: UHCprovider.com > Sign In > Prior Authorization and Notification tool
Phone numbers shown in individual callouts (or 800-445-1638 / 888-397-8129 for general PA assistance)

Prior Authorization

Prior authorization for colony-stimulating factors and select oncology agents

Colony-stimulating factors, select oncology agents and certain bone-modifying agents require prior authorization. Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

Prior authorization via Provider Portal or by phone: 888-397-8129
Include J- or Q-code(s) and clinical indication in request

Definitions, Vendors, and Contact Points

Early and Periodic Screening, Diagnostic and Treatment

DefinitionEPSDT = Early and Periodic Screening, Diagnostic and Treatment.

Coverage implicationEPSDT enables medically necessary services for members younger than 21 that may not be covered for adults (example: allergy immunotherapy covered <21).

ReferenceProviders should refer to AHCCCS Medical Policy Manual Chapter 400, Section 430 for EPSDT guidance and documentation requirements.

multi-specialty interdisciplinary clinics

DefinitionMulti-specialty interdisciplinary clinics (MSIC) — services delivered inside MSIC to CRS-designated members do not require prior authorization.

ApplicabilityApplies to children's rehabilitative services (CRS)-designated members receiving care within MSIC.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements and submission methods — UnitedHealthcare Community Plan (Arizona)

Policy CodePolicy N/A

Change TypeAdministrative (no material changes)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or call 888-397-8129 / 800-445-1638.

SourceLink

On This Page

Site‑of‑service (SOS) rule: Prior authorization is required when requesting service in an outpatient hospital setting; prior authorization is not required if the procedure is performed at a participating ambulatory surgery center (ASC) for certain listed items.

Wound vacuum therapy (E2402) requires prior authorization.

Action for providersFollow AHCCCS coverage definitions and include medical necessity documentation when requesting EPSDT-related services for members <21.

DME retail/rental cost threshold

ThresholdPrior authorization required for DME items when retail purchase or cumulative rental cost exceeds specified thresholds.

Vendor contactTo request DME items or incontinence supplies call Preferred Homecare at 800-636-2123.

Alternate vendorsIf services are not covered by Preferred Homecare, review UnitedHealthcare Community Plan Provider Manual for contracted vendors at UHCprovider.com/AZcommunityplan.

Orthotic cost threshold

Cost triggerOrthotics/prosthetics items with a cost greater than $500 may trigger prior authorization or retail limitation.

Codes referencedNumerous L‑codes (orthotics/prosthetics) listed; age-based rules and AHCCCS orthotics coverage rules apply.

Out-of-network servicesPrior authorization is required for all out-of-network orthotics and prosthetics services.

Prior Authorization

Durable medical equipment prior authorization (CGM and vendor information)

Prior authorization is required for many DME items and certain vendors are preferred for supplies. For continuous glucose monitors (CGMs) prior authorization is required when billed for members age 21 and older with type 2 diabetes. To request DME items call Preferred Homecare at 800-636-2123. For DME not provided by Preferred Homecare, review the Provider Manual or the contracted vendor list at UHCprovider.com/AZcommunityplan > Member Handbooks.

CGM prior authorization required with type 2 diabetes diagnosis (members 21+)
To request incontinence supplies or other DME provided through Preferred Homecare call 800-636-2123
For DME services not covered by Preferred Homecare, use contracted vendor list at UHCprovider.com/AZcommunityplan

Prior Authorization

Cochlear implant prior authorization

Cochlear implant procedures and associated HCPCS/CPT codes require prior authorization. For members younger than 21, cochlear-related codes below require prior authorization. Submit requests online via the Provider Portal or call 888-397-8129.

Prior authorization required for listed cochlear CPT and HCPCS codes
Submit clinical documentation and device details with the PA request
Call 888-397-8129 for assistance

Prior Authorization

DME prior authorization and vendor

Durable Medical Equipment (DME) prior authorization and vendor instructions: Preferred Homecare is the primary vendor for many DME supplies. To request items or supplies through Preferred Homecare call 800-636-2123. Prior authorization is required for DME items listed and for items with a retail purchase or cumulative rental cost above plan thresholds. For services not covered by Preferred Homecare, review the contracted vendor list in the Provider Manual at UHCprovider.com/AZcommunityplan > Member Handbooks.

Prior authorization required for listed DME codes and items exceeding retail/rental thresholds
Use Preferred Homecare for in-network DME supplies and incontinence supplies
For non-Preferred Homecare needs, follow Provider Manual vendor guidance

Prior Authorization

Eye care prior authorization / contact

Eye care services for members age 21 and older require prior authorization when medically necessary to diagnose or treat eye disease or conditions. For member eye care services contact Nationwide Vision at 480-961-1702. Members younger than 21 have specified comprehensive benefits (routine exam, lenses, frame allowances) without prior authorization for routine services per EPSDT rules.

Prior authorization required for medically necessary eye procedures for members 21+
Routine pediatric eye services (members <21) covered per EPSDT; review AMPM Chapter 400, Section 430

Prior Authorization

Injectable medication prior authorization codes (sample) and submission guidance

Injectable chemotherapy and many physician-administered injectable medications require prior authorization. Include appropriate J-/C-/Q- or other HCPCS/CPT code(s), NDC(s) where applicable, indication and clinical documentation with each request. For pharmacy prior authorization contact UnitedHealthcare Pharmacy Prior Authorization Service (phone 800-310-6826; fax 866-940-7328).

Service requests must include J-codes and NDC codes when applicable
Use Provider Portal for medical benefit injectable PA or pharmacy PA contact above for pharmacy-administered drugs
For specialty pharmacy prior authorization, fax to 866-940-7328

Prior Authorization

Listed injectable HCPCS/CPT codes requiring prior authorization

UnitedHealthcare requires prior authorization for a broad list of injectable HCPCS/CPT codes. This includes many J-codes, Q-codes, and certain C-/temporary/unclassified codes when associated with specific high-cost or newly marketed drugs. For unclassified and temporary codes (for example C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590) prior authorization is required only when used for certain products (e.g., Nulibry, Revcovi, Rivfloza, Vabysmo) as noted in the policy. Use the Provider Portal or call 888-397-8129 to submit PA requests.

Prior authorization required for J9000-J9999 chemotherapy range and many other J/Q codes
Check 'Review at Launch' and plan drug policies for newly approved medications requiring pre-determination
Include clinical indication, regimen, and relevant prior treatments when submitting PA

Prior Authorization

Orthotics and prosthetics — prior authorization

Orthotics and prosthetics (O&P) require prior authorization for many L-codes. Authorization is required to ensure the item is medically necessary and consistent with coverage guidelines (including Medicare-consistent criteria). PA is required for out-of-network services. Submit PA requests via the Provider Portal and include the L-code(s), clinical rationale, and treating provider details.

Prior authorization required for listed L-codes and many custom devices
Requests should document conservative treatments tried and the medical necessity for the device
Out-of-network O&P services require PA

Prior Authorization

Surgical prior authorization and site-of-service rules

Surgical procedures and site-of-service rules: Prior authorization is required for many surgical CPT codes. Some procedures require authorization only when performed in an outpatient hospital setting (Site-of-Service [SOS] rule); the same procedures may not require PA if performed at a participating ambulatory surgery center (ASC). Examples include select arthroscopic and endoscopic procedures where SOS applies. Submit PA via the Provider Portal or call 866-889-8054. When PA is required, include operative indication and planned site of service.

Include planned site of service (outpatient hospital vs ASC) with the PA request
If requesting outpatient hospital for a code with SOS restriction, provide clinical rationale for hospital setting
ASC site-of-service exception: PA may not be required when procedure is scheduled at a participating ASC

Prior Authorization

Sinuplasty prior authorization

Sinuplasty (balloon sinuplasty) codes require prior authorization. The codes listed below require PA for outpatient performance. Submit the request via the Provider Portal or call 866-889-8054 and include diagnostic imaging and prior medical therapy documentation.

Provide history of chronic rhinosinusitis symptoms, prior medical management, and imaging (CT) with the PA request
PA required for listed sinuplasty codes

Prior Authorization

ASC site-of-service exception

ASC site-of-service exception: Prior authorization is not required for certain procedures when performed at a participating ambulatory surgery center (ASC). If a procedure would normally require PA when done in an outpatient hospital setting, document the ASC location to determine whether SOS PA rules apply. When requesting an outpatient hospital site for a procedure with an ASC exception, include clinical justification for hospital setting during the PA request.

PA may be waived for eligible codes when performed at a participating ASC
If requesting outpatient hospital instead of ASC for codes with SOS exception, include medical justification with PA

Provider noteOnly one health care professional may request services on a prior authorization request form.

Injectable chemotherapy prior authorization (outpatient)

RequirementPrior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis.

Code range examplesIncludes chemotherapy injectable drugs billed under J9000-J9999 and specific leucovorin/levoleucovorin codes (e.g., J0640, J0641).

SubmissionSubmit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129 for assistance.

Inpatient video seizure monitoring PA requirement

GuidanceInpatient video seizure monitoring CPT codes (95714-95718) are indicated as prior authorization not required for inpatient video monitoring.

Contrast with outpatientCertain cerebral seizure monitoring codes (e.g., 95700, 95711-95713) and outpatient EEG codes (95720, 95722, 95724, 95726) require prior authorization.

Provider actionWhen scheduling inpatient video monitoring, PA is not required; for outpatient EEG or cerebral monitoring, obtain PA per listed codes.

EPSDT guidance (members <21)

GuidanceFor members younger than 21, EPSDT guidance applies; providers should consult AHCCCS AMPM Chapter 400, Section 430 for PA and Certificate of Medical Necessity requirements.

ExamplesEPSDT can make medically necessary services (e.g., allergy immunotherapy for <21) eligible even if not covered for adults.

ContactPreferred Homecare is the contact for requesting certain supplies and DME for members <21 (800-636-2123).

Preferred Homecare (DME vendor)

VendorPreferred Homecare is the contracted DME vendor to request DME items and incontinence supplies; call 800-636-2123.

Benefit restrictionIncontinence supplies are a benefit only when provided through Preferred Homecare.

Alternate vendor instructionIf services are not covered by Preferred Homecare, review UHCprovider.com/AZcommunityplan for contracted vendors and instructions.

Optum Infusion contact

ContactOptum Infusion handles requests for infusion in-home services and many injectable medications; call 888-705-4470.

ScopePrior authorization is required for in-home infusion services and injectable medications not covered by the vendor.

Provider instructionTo request medications or supplies for in-home infusion, call Optum Infusion at the listed number.

Incontinence supplies vendor requirement

RequirementIncontinence supplies are covered only when provided through Preferred Homecare; providers must call Preferred Homecare to request supplies.

PhonePreferred Homecare: 800-636-2123.

ApplicabilityApplies to members younger than 21 and to other members where policy indicates vendor requirement.

Injectable medications

RequirementPrior authorization is required for many listed injectable medications; see the HCPCS/J-code lists in the policy for specifics.

ExamplesSample codes listed include J2350 (octreotide acetate) and numerous branded/biologic J‑codes (e.g., J2267, J1745, J1930, Q5135).

Unclassified codes noteUnclassified/temporary codes (e.g., J3490, J3590, C9xxx) require PA only for specified products per the policy (see Review at Launch and section notes).

Review at Launch policy — pre-determination recommendation

PolicyReview at Launch for New to Market Medications lists newly FDA‑approved drugs recommended for pre-determination; pre-determination is highly recommended for drugs on that list.

How to obtain PAFor prior authorization, submit requests online using the UnitedHealthcare Provider Portal or call 888-397-8129.

LocationReview at Launch policy available at UHCprovider.com/policies > For Community Plans > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

State Medicaid (Arizona) orthotics coverage rules that apply to members

ApplicabilityAHCCCS orthotics coverage rules apply to members; orthotics are covered per state Medicaid rules with age- and setting-based considerations.

Cost guidanceSome orthotics/prosthetics items list a retail cost threshold (e.g., cost of more than $500 may trigger PA or retail limitation).

Codes and settingsNumerous L‑codes are enumerated and coverage may vary by facility type (acute care hospitals, inpatient rehab, LTACH).

Prior Authorization and Notification tool (UnitedHealthcare Provider Portal)

ToolUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit PA requests (UHCprovider.com).

Phone alternativesFor assistance or code-specific authorizations call 888-397-8129 (general PA) or 866-889-8054 for radiology/advanced imaging inquiries.

AccessSign in with One Healthcare ID to access the Provider Portal and select the Prior Authorization and Notification tool on the dashboard.

Qualified Medicare Beneficiary (QMB) coverage distinction for speech therapy

QMB distinctionOutpatient speech therapy is not a covered benefit for members 21 and older, but for QMB members speech therapy services are covered when medically necessary.

PA timingPrior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits.

No annual limits for <21For members younger than 21, speech therapy services are covered when medically necessary with no annual benefit limits (requests reviewed for medical necessity).

SOS - outpatient hospital

DefinitionSOS - outpatient hospital: Site-of-service rule where prior authorization is required when requesting services in an outpatient hospital setting.

ASC exceptionPrior authorization is not required if the procedure is performed at a participating ambulatory surgery center (ASC) for certain items.

Provider actionConfirm site of service when submitting PA; PA may be required for outpatient hospital but not for participating ASC for listed procedures.

ASC

DefinitionASC = Ambulatory Surgery Center. Participating ASCs may not require prior authorization for some procedures listed in the policy.

ExceptionIf service is at a participating ASC, PA may not be required (confirm participation and policy applicability).

Provider noteWhen requesting services, verify whether the ASC is participating to determine PA necessity.

Transplant/CAR T-cell therapy

CoordinationFor transplant and CAR T-cell therapy services, contact the UnitedHealthcare Community and State Transplant Case Management Team at 800418-4994 or use the notification number on the back of the member's ID card.

DocumentationClinical documentation to support the need for transplants must accompany and establish medical necessity for the service request.

ExamplesApplies to listed CAR T-cell therapy products (e.g., Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) which require notification and coordination.

VAD notification

NotificationFor Ventricular Assist Devices (VAD), 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.

DefinitionVAD = Ventricular Assist Device, a mechanical pump that takes over the function of a damaged ventricle.

PA requirementPrior authorization is required for listed VAD codes; follow the notification and fax process described in the policy.