CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements — UnitedHealthcare Community Plan of Arizona (ACC)

Governs prior authorization submission requirements and lists services/CPT/HCPCS codes that require prior authorization for providers participating with the UnitedHealthcare Community Plan of Arizona Complete Care (ACC) Medicaid program. Affects participating health care professionals, facilities and vendors rendering inpatient and outpatient services in Arizona.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements — UnitedHealthcare Community Plan of Arizona (ACC)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

online & phonesubmission channels for prior authorization

EPSDT <21EPSDT applies <21

manyservice categories with PA lists

PA requiredinjectable chemotherapy

SOS rules

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.

site-of-service rules

800-636-2123Preferred Homecare contact

Coverage Criteria and Rules

Summary of coverage stance, prior authorization requirements, and notable rules (consolidated from source).

All services must be covered benefits per AHCCCS and be medically necessary, cost-effective, federally- and state-reimbursable; experimental or investigational services are not covered (provider must confirm AHCCCS eligibility).

Prior authorization is required for services provided by non-network and out-of-state providers; documentation supporting out-of-network requests must accompany the PA.

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

Providers, facilities and vendors must be actively registered with AHCCCS to render services eligible for prior authorization.

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

When specific items require prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the listed phone numbers (commonly 888-397-8129 or program-specific numbers such as 866-889-8054, 800-788-9743, 800-418-4994, 888-705-4470, 800-636-2123, 888-700-6822).

Injectable chemotherapy drugs administered outpatient (IV, intravesical, intrathecal) for cancer require prior authorization; includes J9000-J9999 range, specified J-codes (e.g., J0640, J0641, J0642, J1950), Q-codes and miscellaneous HCPCS-billed agents.

Many physician-administered and pharmacy drugs require prior authorization — a non-exhaustive list of J- and Q-codes is provided in source (examples: J1442, Q5110, J2506, J2820, J1447, J1448, J0897, J0885, J0129, J1745, J9312, J9311, J1412, J0896, J2998, J1301, J1203).

Inpatient admissions and certain post-acute facility admissions require notification and/or prior authorization (acute care hospitals, inpatient rehab, LTAC).

Unclassified/temporary HCPCS and J-codes (e.g., C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590) require prior authorization only for specific products (examples listed in source).

Transplant and CAR T-cell therapies require specialized authorization routing — contact UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 and include documentation to establish medical necessity.

Orthotics/prosthetics and durable medical equipment require prior authorization when retail purchase or cumulative rental cost exceeds $500; many device L-codes listed require PA (examples: L8499, L8609, L8610, L8612, L8631, L8614, L8619, L8690–L8692).

Out-of-state services are covered only when emergent or unavailable in Arizona; prior authorization required for out-of-network services.

Outpatient therapy (physical, occupational, speech): prior authorization required after initial evaluation and before the initial therapy visit and for ongoing therapy; speech therapy is covered for members <21 (no annual limits) but not covered for members 21 and older except QMB members (see AMPM references).

Allergy immunotherapy: For members <21, allergy immunotherapy and testing are covered under EPSDT when medically necessary; for members 21+, allergy immunotherapy (shots, SLIT, other routes) is not covered. Allergy testing requires PA if criteria such as prior anaphylactic reaction to unknown allergen or severe reaction predictive of life-threatening exposure are met.

Specific procedures and services listed require prior authorization — examples include radiology advanced outpatient imaging (certain CT/MRI/MRA/PET, nuclear medicine), proton beam therapy (CPT 77520–77525), orthognathic surgery (CPTs listed), joint replacements, hysterectomy codes, non-emergent air ambulance (A0430, A0431, A0435, A0436), sleep apnea surgeries, vein procedures (36473, 36475, 36478, 37700), wound vac (E2402), specialty beds (E0250 series), and many CPT/HCPCS codes enumerated in the radiology and procedures lists.

Certain services are routed to vendor partners: in-home infusion — Optum Infusion (888-705-4470); incontinence and supplies — Preferred Homecare (800-636-2123); laboratory — Labcorp (800-788-9743); transportation scheduling — MTM (888-700-6822).

Cosmetic services that change or improve appearance without significant improvement/restoration are excluded; prior authorization is required for listed cosmetic/reconstructive codes when applicable.

For members younger than 21, EPSDT/AMPM policies apply for many services (see AMPM Chapter 400 references provided in source); certificates of medical necessity and AMPM forms must accompany PA requests when specified (e.g., pregnancy termination, oral nutritional supplements).

Codes and Coding Tables

Provider Actions, Contacts, and How to Request Authorization

Prior Authorization

How to submit prior authorization requests (portal and phone)

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) or by phone at 800-445-1638. For certain drug prior authorization and oncology supportive agents, providers may call 888-397-8129 and the document lists specific submission instructions for those drugs.

Online: UHCprovider.com > Sign In > Prior Authorization and Notification tool (One Healthcare ID required)
Phone: 800-445-1638 for general PA requests
Drug/oncology support: 888-397-8129 (per specific sections and drug lists)

Prior Authorization

Eligibility and general PA rules (AHCCCS, out-of-network/out-of-state)

Only services that are AHCCCS-covered benefits are eligible for prior authorization; services provided by non-network or out-of-state providers require prior authorization with supporting documentation. Experimental and investigational services are not covered benefits.

Definitions and Notes

inv-100: AHCCCS-covered benefits

DefinitionAHCCCS-covered benefits: Services must be covered benefits as defined by the Arizona Health Care Cost Containment System (AHCCCS) to be eligible for prior authorization.

Eligibility noteAll rendering health care professionals, facilities and vendors must be actively registered with AHCCCS.

Coverage exclusionsExperimental and investigational services are not covered benefits under AHCCCS and therefore not eligible for coverage.

inv-101: Oncology supportive services requiring prior authorization

ScopeInjectable colony-stimulating factors and certain bone-modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization.

Example agents/codesExamples include filgrastim (J1442), pegfilgrastim (J2506) and denosumab for bone-modifying therapy (J0897); multiple biosimilar Q-codes are also listed.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements — UnitedHealthcare Community Plan of Arizona (ACC)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

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

SourceLink

On This Page

Services must be AHCCCS-covered to be eligible for PA

Non-network and out-of-state services require PA plus documentation supporting the out-of-network request

Experimental/investigational services are not covered

Prior Authorization

Service-specific PA requirements and example CPT/HCPCS codes

Prior authorization is required for many specified service categories and example CPT/HCPCS codes listed in the document (e.g., augmentative/alternative communication codes 92607–92609, A9901; bariatric surgery codes 43644, 43645, 43846; oncology supportive agent J-codes). Follow the submission instructions in the corresponding sections.

Augmentative/alternative communication: 92607, 92608, 92609, A9901, E25xx series
Bariatric surgery examples: 43644, 43645, 43659, 43770, 43775, 43842–43860
Oncology supportive agents: filgrastim J1442/Q5110/Q5125; pegfilgrastim J2506/Q5122/Q5120/Q5111; denosumab J0897 — PA and submission instructions provided

Prior Authorization

Cardiology prior authorization requirements

Cardiology and cardiovascular procedures (including outpatient diagnostic catheterizations, electrophysiology implants, stress echocardiography and listed vascular CPTs) require prior authorization; submit via the Provider Portal Prior Authorization and Notification tool or call 866-889-8054 for cardiology-specific requests.

PA required for outpatient/office-based diagnostic catheterizations and electrophysiology implants
Use Provider Portal tool or call 866-889-8054 for cardiology PA

Prior Authorization

Prior authorization for outpatient injectable chemotherapy

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical and intrathecal) including chemotherapy injectable drugs billed under J9000–J9999 and related miscellaneous/Q-coded or unassigned HCPCS codes; submit requests via the Provider Portal or call the provider number listed in the chemotherapy section.

Affected drugs: chemotherapy injectables (J9000–J9999), leucovorin (J0640–J0642), Lupron Depot (J1950), Q-coded chemotherapy agents and miscellaneous HCPCS-billed agents
Submit PA via Prior Authorization and Notification tool on UHCprovider.com or call the provider number referenced

Prior Authorization

Seizure monitoring and EEG PA distinctions

Select cerebral seizure monitoring codes (e.g., 95700, 95711–95713, 95720–95726) require prior authorization for outpatient monitoring; inpatient video monitoring codes (95714–95718) do not require prior authorization for inpatient video monitoring.

PA required: 95700, 95711, 95712, 95713, 95720, 95722, 95724, 95726
No PA required for inpatient video monitoring: 95714, 95715, 95716, 95718

Prior Authorization

Procedures, devices and other service codes requiring PA or with coverage notes

Multiple procedures, devices and other services listed (e.g., cochlear device codes 69710, 69714, 69930 and L-code device entries; continuous glucose monitor codes A4226, A9277, A4238, A9278; cosmetic/reconstructive and many surgical CPTs) require prior authorization or have specific coverage notes; contact the provider PA line for code-specific guidance.

Cochlear/device codes: 69710, 69714, 69930, L8614–L8692 series
Continuous glucose monitor supplies/equipment: A4226, A9277, A4238, A9278, A4239, E0787
Cosmetic/reconstructive procedures: many CPTs listed; services solely for cosmetic purposes are excluded from AHCCCS coverage

Note

Provider prior authorization contact number

For prior authorization instructions and code information, providers may call the UnitedHealthcare provider help line at 888-397-8129; this number is referenced repeatedly throughout the document for PA inquiries.

Provider prior authorization help line: 888-397-8129

Prior Authorization

DME prior authorization and Preferred Homecare vendor

Durable medical equipment (DME) items listed require prior authorization and requests for DME and enteral services/supplies should be made through Preferred Homecare at 800-636-2123, which is the designated vendor for these items.

Preferred Homecare for DME and enteral: 800-636-2123
PA required for listed DME codes and when retail purchase or cumulative rental cost thresholds apply

Documentation Required

Enteral/parenteral prior authorization process and documentation

To request enteral or parenteral services and supplies (including clinical documentation and the Certificate of Medical Necessity when applicable), call Preferred Homecare at 800-636-2123; clinical documentation and the certificate must accompany requests as applicable.

Preferred Homecare contact: 800-636-2123
Include clinical documentation and Certificate of Medical Necessity where applicable

Prior Authorization

Nationwide Vision contact for eye care prior authorization

Member eye care prior authorization and service questions are handled by Nationwide Vision; providers should call Nationwide Vision at 480-961-1702 for member eye care PA and service inquiries.

Nationwide Vision contact for member eye care PA: 480-961-1702

Prior Authorization

Experimental/investigational services require prior authorization

Experimental and investigational services require prior authorization and are listed with specific codes in the document; the AMPM references apply and prior authorization is required for the listed experimental/investigational codes.

Experimental/investigational services: PA required; example codes include 33477, A4638, G0293, S9991, 36514, A9274, G2000

Prior Authorization

Pediatric hearing services — PA exceptions for <21

Hearing evaluations and hearing aids for members younger than 21 do not require prior authorization for specified codes (e.g., 92590–92593); other hearing V-codes and age-based rules are noted in the document.

No PA required for hearing evaluations/hearing aids: 92590, 92591, 92592, 92593 (members <21)
Other hearing V-codes and age-based coverage notes are listed

Prior Authorization

In-home infusion services and injectable medication PA (Optum Infusion)

Prior authorization is required for infusion in-home services and injectable medications not covered by Optum Infusion; to request these services or supplies, call Optum Infusion at 888-705-4470.

Optum Infusion contact for in-home infusion requests: 888-705-4470
PA required for services not covered by Optum Infusion

Prior Authorization

Hysterectomy PA requirement for members younger than 21

Prior authorization is required for the listed hysterectomy procedure codes when performed on members younger than 21; see the hysterectomy section for the specific CPT codes that require PA.

Hysterectomy CPTs listed requiring PA for members <21: 58150, 58152, 58180, 58200, 58210, 58240, 58260–58270 series

Billing Rule

Incontinence supplies — vendor requirement (Preferred Homecare)

Incontinence supplies are a covered benefit only when provided through Preferred Homecare; providers must request incontinence supplies through Preferred Homecare.

Preferred Homecare handles incontinence supply requests (call the Preferred Homecare number)
Incontinence supplies are a benefit only when provided through this vendor

Prior Authorization

Hearing evaluations and hearing aids — PA not required for specified pediatric codes

Certain hearing evaluations and hearing aids (codes 92590–92593) for members younger than 21 do not require prior authorization; other hearing-related codes and V-codes have age-based coverage distinctions noted in the document.

No PA required for 92590–92593 for members <21
Additional hearing V-code notes apply for other ages

Prior Authorization

Selected injectable medications and J-/Q-codes requiring PA

A broad list of injectable medications and associated HCPCS/J-codes require prior authorization; examples listed include J0129, J2267, J0222, J1576, J0606, J1745, J9312, J9381 and many others — consult the document sections for full lists and submission instructions.

Selected injectable J-/Q-codes: J0129, J2267, J0222, J1576, J0606, J1745, J9312, J9381
Full injectable medication lists and PA instructions are provided in the document

Prior Authorization

Additional injectable medication codes requiring PA

Additional injectable HCPCS/J-codes and class-specific codes (e.g., J7320–J7332, J1930, Spevigo J1747, Stelara, Q9991/Q9992) are identified as requiring prior authorization; refer to the medication sections for exact code groupings and submission details.

Additional example codes: J7320–J7332 series, J1930, J1747, Q9991, Q9992
Consult the injectable medication sections for complete lists

Prior Authorization

Unclassified/C/Q codes and intravitreal VEGF — PA references

Unclassified and miscellaneous HCPCS/C/J codes (e.g., C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590) and intravitreal VEGF J-codes (J0178, J0179, J2777, J2778) are referenced for prior authorization and have special handling notes in the document.

Unclassified/temporary codes listed: C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590
Intravitreal VEGF examples: J0178, J0179, J2777, J2778

Prior Authorization

How to obtain prior authorization and required actions

Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129; certain unclassified/temporary codes require PA only for specific drugs (Nulibry, Revcovi, Rivfloza, Vabysmo). Follow the document instructions and include supporting documentation as noted.

Portal submission: UHCprovider.com (One Healthcare ID sign-in)
Phone submission: 888-397-8129 for many PA requests
Unclassified/temporary codes C9094/C9149/C9157/C9166/C9172/C9399/J3490/J3590: PA required only when used for specific drugs (Nulibry, Revcovi, Rivfloza, Vabysmo)

Documentation Required

Admission notification and admission date reporting requirements

Notification of inpatient admissions is required for acute care hospitals, acute inpatient rehabilitation and long-term acute care hospitals; prior authorization and admission date notification must be provided as specified.

Notification required for admissions and admission date reporting for listed facility types
Use the Provider Portal or call 888-397-8129 per instructions

Prior Authorization

Laboratory prior authorization contact (Labcorp)

For laboratory prior authorization or scheduling, providers should contact Labcorp at 800-788-9743 as directed in the laboratory services section.

Labcorp contact for lab PA/scheduling: 800-788-9743

Prior Authorization

Unclassified/temporary codes — PA only for specified drugs

For the unclassified and temporary drug codes listed (C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590), prior authorization is required only when those codes are used for specific drugs (Nulibry, Revcovi, Rivfloza, Vabysmo); otherwise PA is not required for other uses of these codes.

PA required for these temporary/unclassified codes only when billed for Nulibry, Revcovi, Rivfloza or Vabysmo
Use Provider Portal or call 888-397-8129 to obtain PA

Billing Rule

Orthotics/prosthetics PA threshold — $500 retail/rental

Orthotics and prosthetics codes listed require prior authorization when the retail purchase or the cumulative rental cost exceeds $500; some L-codes include additional member age notes (e.g., special rules for members younger than 21).

Orthotics/prosthetics PA threshold: retail purchase or cumulative rental cost > $500
Selected L-codes (e.g., L1840, L1844–L1846) have member age–based notes

Prior Authorization

Unclassified/temporary codes — PA limited to specific drugs

For unclassified and temporary codes C9094, C9149, C9157, C9166, C9172, C9399, J3490 and J3590, prior authorization is required only for the specific drugs Nulibry, Revcovi, Rivfloza and Vabysmo; otherwise these temporary codes do not automatically require PA.

Specified temporary/unclassified codes: C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590
PA applies only when used for Nulibry, Revcovi, Rivfloza or Vabysmo

Prior Authorization

Out-of-network services require prior authorization

Prior authorization is required for all out-of-network services; providers must obtain PA when services are furnished by non-participating providers.

Out-of-network services require prior authorization

Prior Authorization

Out-of-state service PA limitation — emergent or unavailable in Arizona

Out-of-state services are approved only when the service is emergent or unavailable in the state of Arizona; prior authorization must reflect these limitations.

Out-of-state services: benefit approval only when emergent or unavailable in Arizona

Prior Authorization

Therapy prior authorization timing — obtain PA after evaluation and before initial visit

Prior authorization for therapy services is required after the initial evaluation and before the initial therapy visit and is required for all ongoing therapy visits; this timing applies to occupational and physical therapy and to speech therapy for members under 21 and QMB members as noted.

Obtain PA after the initial evaluation and before the initial therapy visit
PA is required for ongoing therapy visits
Applies to PT/OT and speech therapy (members <21 and QMB exceptions noted)

Prior Authorization

Speech therapy PA and coverage (members <21)

Outpatient speech therapy for members younger than 21 is covered when medically necessary and requires prior authorization after the initial evaluation and before the initial visit and for ongoing visits; outpatient speech therapy is not a covered benefit for members 21 and older.

Covered and PA required for members <21: codes 92507, 92508, 92526
Not covered for members 21 and older

Prior Authorization

Pain management and injection procedures require prior authorization

Pain injections and pain management procedures require prior authorization; see the pain management section for listed CPT examples (e.g., 64490, 64493) and submission guidance.

PA required for pain injection procedures such as 64490 and 64493

Prior Authorization

Pharmacy and physician-administered drug prior authorization resources

A list of pharmacy and physician‑administered drugs requiring prior authorization is available on the UHC Arizona community plan site (UHCprovider.com/AZcommunityplan > Pharmacy Resources and Physician Administered Drugs); example J‑codes are provided in the medication sections.

Medication PA list location: UHCprovider.com/AZcommunityplan > Pharmacy Resources and Physician Administered Drugs
Example J-codes: 90378, J1299, J1429, J2840, J0224, J1303

Prior Authorization

Outpatient speech therapy — PA timing and coverage details

Outpatient speech therapy PA requirements and coverage: prior authorization required after initial evaluation and before the initial therapy visit and for all ongoing visits for members under 21 and QMB members; outpatient speech therapy is not covered for members 21 and older.

PA timing: after initial evaluation and before initial visit, and for ongoing visits
Codes: 92507, 92508, 92526

Prior Authorization

Radiology prior authorization and notification requirements

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) requires notification prior to scheduling and often requires prior authorization; submit imaging PA requests via the Provider Portal or call 866-889-8054 for radiology program inquiries.

Notification prior to scheduling is required for advanced outpatient imaging
Submit PA via Prior Authorization and Notification tool or call 866-889-8054
Refer to UHCprovider.com/AZcommunityplan > Radiology Prior Authorization and Notification Program for code lists

Prior Authorization

Site-of-service prior-authorization rules and SOS differences

Site-of-service rules apply: certain CPTs require prior authorization only when performed in an outpatient hospital setting and may not require PA when performed at a participating ambulatory surgery center (ASC); consult the site-of-service notes and Radiology/Provider Portal resources for specific CPT guidance.

PA may be required only for outpatient hospital site of service for some CPTs
Check UHCprovider.com/AZcommunityplan for code- and SOS-specific guidance

Note

Pharmacy / physician-administered drugs — where to find PA lists

Refer to the online medication lists at UHCprovider.com/AZcommunityplan for pharmacy and physician-administered drugs that require prior authorization; example HCPCS J-codes are provided in the policy for reference.

Medication PA list: UHCprovider.com/AZcommunityplan > Pharmacy Resources and Physician Administered Drugs
Example HCPCS J-codes included in the policy

Documentation Required

Pregnancy termination — prior authorization and required documentation

Pregnancy termination requires prior authorization; clinical documentation and the Certificate of Medical Necessity for Pregnancy Termination must accompany the PA request per AMPM Chapter 400 guidance.

PA required and must include clinical documentation and Certificate of Medical Necessity
See AMPM Chapter 400, Section 410 for forms and guidance

Prior Authorization

Private-duty nursing — prior authorization required

Private-duty nursing services require prior authorization for the listed codes (e.g., T1002, T1003); submit PA requests per the Provider Portal or phone instructions.

PA required for private-duty nursing codes: T1002, T1003
Use Provider Portal or phone per PA submission guidance

Prior Authorization

How to obtain prior authorization — portal and phone options

Providers may request prior authorization for listed CPT/HCPCS codes via the UnitedHealthcare Provider Portal dashboard or by calling the specified phone numbers (e.g., 866-889-8054 for radiology requests); follow the portal instructions and include required supporting documentation.

Provider Portal dashboard is primary method for many PA requests
Phone numbers provided for program-specific lines (radiology: 866-889-8054; general: 888-397-8129)

Documentation Required

Site-of-service annotations may affect authorization requirements

Some codes include site-of-service annotations (e.g., outpatient, outpatient hospital) which may affect whether prior authorization is required; verify the code's site-of-service note in the policy when preparing a PA request.

Check site-of-service annotations (SOS) for outpatient vs outpatient hospital
SOS may change PA requirement for a given CPT

Prior Authorization

Transplant and CAR T-cell therapy prior authorization pathway

For transplant and CAR T-cell therapy services (including listed CAR-T products), contact the UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 or use the notification number on the member's ID card; clinical documentation must accompany requests to establish medical necessity.

Transplant/CAR-T contact: UnitedHealthcare Transplant Case Management Team at 800-418-4994
Include clinical documentation to support medical necessity

Prior Authorization

General PA requirements for surgeries, specialty beds and facility services

Prior authorization is required for many surgical and facility services listed (e.g., spinal surgery CPT ranges, specialty/enclosed beds E0250–E0316, skilled nursing facility services, sterilization and sleep apnea surgeries); include documentation where noted (e.g., transplant requests).

Spinal surgery codes (e.g., 22100–22899, 63001–63308) require PA
Specialty/enclosed beds and certain DME require PA (E0250–E0316 series)
Skilled nursing facility services and sleep apnea surgeries require PA

Prior Authorization

Transplant and CAR T-cell therapy — contact and PA requirement

For transplant and CAR T-cell therapy (including multiple CAR-T products), contact the UnitedHealthcare Community and State Transplant Case Management Team at 800-418-4994 or use the notification number on the member's ID card; prior authorization is required for these services.

Transplant/CAR-T PA contact: 800-418-4994
Use notification number on member's ID card as applicable

Prior Authorization

Non-emergent transportation — PA and MTM scheduling

Prior authorization is required for non-emergent taxi and stretcher van transportation; to schedule, call Medical Transportation Management (MTM) at 888-700-6822 as directed.

MTM scheduling number for non-emergent transportation: 888-700-6822
PA required for non-emergent taxi and stretcher van services

Prior Authorization

VAD prior authorization — notification and Optum VAD fax

Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the back of the member's ID card and fax the form to the Optum VAD Case Management Team at 855-282-8929.

Call the notification number on member's ID card for VAD PA
Fax required form to Optum VAD Case Management Team: 855-282-8929

Prior Authorization

Code 38232 — PA required only for oncology indication

Code 38232 requires prior authorization only when performed for an oncology indication; routine use outside an oncology indication does not require PA per the document note.

38232: PA required only for oncology indications

Prior Authorization

Wound VAC (E2402) prior authorization required

Wound VAC therapy (E2402) requires prior authorization; include the appropriate clinical documentation when requesting authorization.

Wound VAC code requiring PA: E2402

How to request PASubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

inv-102: Injectable chemotherapy (prior auth)

DefinitionInjectable chemotherapy prior authorization applies to injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis.

Code groupsIncludes chemotherapy J-code ranges (J9000–J9999) and specific HCPCS/J-codes (e.g., J0640, J0641) and selected K-codes referenced in the chemotherapy/infusion sections.

How to request PASubmit prior authorization online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the provider number listed in the document.

inv-103: Seizure monitoring prior auth distinction

DistinctionSelect cerebral seizure monitoring codes (e.g., 95700, 95711–95713) require prior authorization, while inpatient video monitoring codes (95714–95718) are listed as not requiring prior authorization for inpatient video monitoring.

Related outpatient EEG codesOutpatient/ASC EEG and monitoring codes (e.g., 95720, 95722, 95724, 95726) are included with authorization guidance.

Action for providersFollow the code-specific prior authorization guidance in the document when billing or scheduling monitoring services.

inv-104: Documentation required for enteral/parenteral and some DME requests

Required documentationRequests for enteral/parenteral services and some DME/enteral supplies must include clinical documentation and a Certificate of Medical Necessity as applicable.

Vendor routingTo request enteral/parenteral services and supplies, call Preferred Homecare at 800-636-2123 as instructed in the document.

Pediatric referenceFor members younger than 21, refer to AHCCCS AMPM Chapter 400 Section 430 (EPSDT) for enteral/parenteral prior authorization rules and required forms.

inv-105: Services requiring prior authorization per AMPM references

RequirementServices determined to be experimental and/or investigational per AMPM references require prior authorization and are not covered unless otherwise specified.

AMPM referencesRefer to AMPM Chapter 300, Section 320, Policy 320-B and other cited AMPM chapters for details on experimental/investigational service handling.

ExamplesThe document lists example CPT/HCPCS codes flagged as experimental/investigational that require review and authorization.

inv-106: Optum Infusion

VendorOptum Infusion is the designated vendor for in-home infusion services referenced; prior authorization is required for services not covered by Optum Infusion.

Contact for infusionTo request infusion services and/or supplies through Optum Infusion, call 888-705-4470 as provided in the document.

ScopeInjectable medications administered in the home and related infusion services are subject to the Optum Infusion routing and prior authorization rules noted.

inv-107: Preferred Homecare

VendorPreferred Homecare is the designated vendor to request incontinence supplies, DME and enteral/parenteral supplies referenced in the document.

ContactTo request incontinence supplies or enteral/parenteral supplies, call Preferred Homecare at 800-636-2123.

Benefit conditionIncontinence supplies are a benefit only when provided through Preferred Homecare as specified for members younger than 21 and general member populations.

inv-108: Injectable medications

DefinitionInjectable medications: multiple J-/Q-codes listed throughout the document identify injectable drugs that require prior authorization or are subject to vendor routing.

Code examplesSelected injectable medication codes appear in the document (e.g., J0129, J2267, J1745, J9312, J9381) and are included in prior authorization lists.

ActionRefer to the listed J-/Q-codes and follow the specified prior authorization submission method (portal or phone) for injectable medications.

inv-109: Intravitreal VEGF

ScopeIntravitreal VEGF injections and related intravitreal drugs are referenced with specific J-codes and are included in the injectable medication prior authorization listings.

Example codesDocument references intravitreal VEGF and example codes such as J0178, J0179, J2777, J2778 alongside unclassified codes (J3490/J3590) in this category.

Provider actionFollow the code-level prior authorization guidance for intravitreal VEGF agents when submitting requests.

inv-110: Notification

Notification requirementNotification is required to inform UnitedHealthcare of inpatient admission and the admission date for specified facilities (acute care hospitals, acute inpatient rehabilitation, long-term acute care hospitals).

How to notifyUse the UnitedHealthcare Provider Portal (One Healthcare ID) or call the provider line (e.g., 888-397-8129) as referenced in the admission/notification sections.

Facilities coveredNotification and prior authorization requirements apply for acute care hospitals, acute inpatient rehabilitation and long-term acute care hospitals as listed.

inv-111: Pre-determination

DefinitionPre-determination: a recommended review prior to providing services or drugs, especially for newly launched medications on the Review at Launch list.

When to useRecommended before providing services or drugs that are new to market or included on the Review at Launch Medication List to confirm coverage and PA requirements.

How to requestSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or follow the portal guidance in the Review at Launch policy.

inv-112: Unclassified/temporary codes

Codes listedUnclassified and temporary drug codes referenced include C9094, C9149, C9157, C9166, C9172, C9399, J3490 and J3590.

PA exceptionPrior authorization for these unclassified/temporary codes is required only when used for specific drugs (Nulibry, Revcovi, Rivfloza, Vabysmo) as noted in the document.

How to obtain PAObtain authorization via the UnitedHealthcare Provider Portal (One Healthcare ID) or call 888-397-8129 for code-specific instructions.

inv-113: Retail purchase or cumulative rental cost

ThresholdPrior authorization is required for orthotics/prosthetics when the retail purchase or cumulative rental cost exceeds $500.

Applies toThis retail/rental cost threshold applies to the orthotics/prosthetics L-code listings referenced throughout the document.

How to obtain PARequest authorization via the UnitedHealthcare Provider Portal or call the provider line (888-397-8129) as instructed in the orthotics/prosthetics sections.

inv-114: Unclassified and temporary codes list

Unclassified/temporary codes listThe document references these unclassified and temporary codes: C9094, C9149, C9157, C9166, C9172, C9399, J3490, J3590.

PA conditionalityPA for these codes is required only for specific named drugs (e.g., Nulibry, Revcovi, Rivfloza, Vabysmo); otherwise PA may not be required for all uses.

Provider instructionUse the Provider Portal (One Healthcare ID) or call 888-397-8129 for code-specific prior authorization requirements and submission instructions.

inv-115: Out-of-network services

RulePrior authorization is required for all out-of-network services provided by non-participating providers.

DocumentationOut-of-network requests must include supporting documentation to justify the out-of-network request as noted in eligibility rules.

Out-of-state limitationOut-of-state services are approved only when emergent or unavailable in Arizona; prior authorization required per policy.

inv-116: Advanced outpatient imaging

DefinitionAdvanced outpatient imaging: certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures that require notification and often prior authorization before scheduling.

Provider responsibilityHealth care professionals ordering advanced outpatient imaging must provide notification prior to scheduling and submit PA via the Provider Portal or call the designated radiology number.

How to submitSubmit via the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054 for radiology PA/notification as instructed.

inv-117: Site of service (SOS)

DefinitionSite of service (SOS): distinction between outpatient hospital and ambulatory surgery center (ASC) that can affect whether prior authorization is required for specific CPTs.

SOS impactSome CPTs require prior authorization only when performed in an outpatient hospital setting and may not require PA if performed at a participating ASC.

Provider actionConfirm site-of-service annotations in the PA guidance and follow the Provider Portal or radiology resources for SOS-specific requirements.

inv-118: Site of service

TermSite of service (SOS) abbreviation is used in the document to indicate location-based PA rules (e.g., outpatient, outpatient hospital, ASC).

UsageSOS annotations alongside CPT/HCPCS codes indicate whether PA is required based on where the service is performed.

ReferenceProviders should consult SOS notes and the Provider Portal for site-specific authorization rules.

inv-119: SOS

AbbreviationSOS stands for Site of Service and is used to denote outpatient vs outpatient hospital or ASC locations where PA requirements can differ.

EffectSOS designation may change whether a CPT requires prior authorization; follow the code-level notes in the document.

ActionUse the Provider Portal and SOS guidance to determine PA requirements for procedures based on service site.

inv-120: UnitedHealthcare Community and State Transplant Case Management Team

Contact teamUnitedHealthcare Community and State Transplant Case Management Team is the designated contact for transplant and CAR T-cell therapy authorization/notification.

Phone numberCall the Transplant Case Management Team at 800-418-4994 or use the notification number on the back of the member's ID card.

DocumentationClinical documentation must accompany transplant requests to establish medical necessity as noted in the transplant section.

inv-121: Ventricular assist devices (VAD)

DefinitionVentricular assist devices (VAD) are mechanical pumps that take over the function of a damaged ventricle and restore cardiac function.

PA requirementVADs require prior authorization; providers should call the notification number on the member's ID card and fax required forms to the Optum VAD Case Management Team at 855-282-8929.

CodesVAD-related CPT/HCPCS codes are listed in the document (e.g., 33927–33983 series) and subject to PA handling.

inv-122: Non-emergent transportation

DefinitionNon-emergent transportation refers to taxi and stretcher van services that require prior authorization and must be scheduled through Medical Transportation Management (MTM).

How to scheduleTo schedule non-emergent transportation, call MTM at 888-700-6822 as provided in the document.

PA requirementPrior authorization is required for non-emergent transportation services before scheduling.