Prior Authorization Requirements and Submission Instructions — UnitedHealthcare Community Plan of Arizona
Governs prior authorization requirements and submission methods for providers participating with UnitedHealthcare Community Plan of Arizona Complete Care (ACC) Medicaid for inpatient and outpatient services in Arizona.
No material clinical or coverage changes in this revision.
Coverage and Eligibility Criteria
General prior authorization coverage criteria and exceptions
Covered when the following eligibility and exceptions are met:
ALL of the following
Eligibility
- Services must be AHCCCS-covered benefits to be eligible for prior authorization.
- Rendering health care professionals, facilities and vendors must be actively registered with AHCCCS.
Network/Location
- Services provided by non-network and out-of-state health care professionals require prior authorization and documentation supporting the out-of-network request.
- Services delivered inside MSIC to CRS-designated/CRS formerly designated members do not require prior authorization.
Exclusions
- Experimental and investigational services are not covered benefits.
- Only medically necessary, cost-effective, federally- and state-reimbursable services are covered per AHCCCS.
- Only one health care professional may request services on a prior authorization request form.
DME and enteral/parenteral coverage rules
Durable medical equipment and enteral/parenteral services are subject to the following rules:
ALL of the following
- Prior authorization is required for the DME codes listed; request DME items through Preferred Homecare at 800-636-2123 or follow the Provider Manual vendor list for items not covered by Preferred Homecare.
- Prior authorization is required for DME codes listed with a retail purchase or a cumulative rental cost above the stated threshold.
- To request enteral/parenteral services and supplies call Preferred Homecare; clinical documentation and certificate of medical necessity (as applicable) must accompany requests.
Age-based coverage stance
Age-based coverage and EPSDT (members younger than 21):
ALL of the following
- For members younger than 21, AHCCCS EPSDT policies (AMPM Chapter 400, Section 430) apply; services covered under EPSDT when medically necessary.
- Prior authorization is required for all services considered experimental and/or investigational for members younger than 21.
- Hearing evaluations and hearing aids for members younger than 21 do not require prior authorization for specified codes; other V-codes have varied PA notes.
Genetic and biomarker testing coverage
Genetic, laboratory and biomarker testing coverage notes:
ALL of the following
- Genetic testing and biomarker codes listed require prior authorization for members younger than 21 as indicated; providers should contact the referenced labs (e.g., Labcorp) or follow the listed prior authorization procedures to obtain approval.
PA criteria excerpt
Selected prior authorization requirements excerpt (high-impact items):
ALL of the following
- Prior authorization is required for all infusion in-home services not covered by Optum Infusion; request via Optum Infusion at 888-705-4470.
- Incontinence supplies are a benefit only when provided through Preferred Homecare and must be requested through Preferred Homecare.
- A lengthy list of injectable medications (HCPCS/J-codes) are listed as requiring prior authorization; providers must reference the specific codes in the document when submitting requests.
- Certain hearing evaluation codes for members younger than 21 do not require prior authorization; other hearing-related V-codes have specific PA notes.
Orthotics/prosthetics and service location criteria
Orthotics, prosthetics and related service-location rules (partial):
ALL of the following
- Orthotics and prosthetics L-codes listed are covered when medically necessary and consistent with AHCCCS/Medicare guidelines.
- Orthotics should be the preferred treatment when medically appropriate and less expensive than alternative treatment options or surgical procedures when applicable.
- For members younger than 21, specific L-codes and documentation/repair rules apply; orthotics must be ordered by a physician or primary care physician as indicated.
- Out-of-state services are approved only when emergent or the service is unavailable in Arizona; out-of-state requests require supporting documentation.
Therapy coverage criteria
Therapy coverage and prior authorization rules by age:
ALL of the following
- Members younger than 21: occupational and physical therapy are covered when medically necessary; no annual benefit limits apply, but prior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits; requests will be reviewed for medical necessity.
- Members 21 and older: prior authorization is not required for occupational and physical therapy.
- Speech therapy: for members younger than 21, speech therapy services are covered when medically necessary and require prior authorization after the initial evaluation and before therapy and for ongoing visits; outpatient speech therapy is not a covered benefit for adults (QMB exceptions may apply).
Medication prior authorization criteria
Medication and specialty pharmacy prior authorization requirements:
ALL of the following
- Service requests for physician-administered or specialty medications must include J Codes and NDC Codes for the medication requested.
- A list of medications requiring prior authorization is available on the provider website (UHCprovider.com/AZcommunityplan) and specialty pharmacy prior authorization forms may be submitted via fax to 866-940-7328.
- Selected high-cost therapeutics, radiopharmaceuticals and hemophilia factor/biotech drugs (examples enumerated in the document) are included on the prior authorization list and require prior authorization as specified.
Coverage criteria summary
Summary of coverage stance and key age/member-type rules:
ALL of the following
- Age 21 and older: occupational and physical therapy do not require prior authorization.
- Age under 21: speech therapy is covered when medically necessary; prior authorization is required after the initial evaluation and before the initial therapy visit and for ongoing visits; requests reviewed for medical necessity.
- QMB members: speech therapy covered when medically necessary; prior authorization requirements align with under-21 rules and medical necessity review applies.
- Advanced outpatient imaging and proton beam therapy require prior authorization and providers must notify prior to scheduling; requests may be submitted via the Provider Portal or by phone (e.g., 866-889-8054).
- Medication PA rules: service requests must include J Codes and NDC codes; specialty pharmacy PAs submitted per pharmacy instructions (fax 866-940-7328).
Prior authorization requirements (partial code lists)
Partial lists and categories of services that require prior authorization (representative examples):
ALL of the following
- Skilled nursing and skilled nursing facility services require prior authorization for the codes listed.
- Specialty/enclosed durable medical equipment and specialty beds (HCPCS E0250–E0316, E0462, etc.) require prior authorization.
- Sterilization procedures require prior authorization for the listed CPT codes and any member requesting sterilization must sign the appropriate Consent for Sterilization form; special rules apply for members younger than 21 as noted.
- Stimulator implantation and bone growth stimulator devices (e.g., E0747–E0749 and various neurostimulator CPT codes) require prior authorization.
- Transplant services and CAR T-cell therapies require prior authorization; clinical documentation to establish medical necessity must accompany requests and providers should contact the Transplant Case Management Team as listed.
- Extensive lists of spinal, neurosurgery, ENT, ophthalmologic, GI endoscopy and other procedural CPT codes are included and flagged for prior authorization in their respective sections (see code lists).
Prior authorization criteria and operational steps
Operational steps and special handling instructions for select service categories:
ALL of the following
- Transplant and CAR T-cell therapy: prior authorization is required; clinical documentation must accompany requests to establish medical necessity and providers should contact the UnitedHealthcare Community and State Transplant Case Management Team as listed.
- Non-emergent transportation (taxi and stretcher van): prior authorization is required; schedule via Medical Transportation Management (MTM) at 888-700-6822.
- 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 the Optum VAD Case Management Team at 855-282-8929.
- Wound VAC (E2402): prior authorization is required for the listed wound vac code(s).
- Code 38232 (stem cell procurement) is a special-case: prior authorization is required only when submitted for an oncology diagnosis.
Codes and Coding Rules
| 37220 | Endovascular embolization or occlusion |
| 37221 | Vascular embolization/occlusion |
| 93580 | Transcatheter valve procedures (example) |
| L8682 | Transplantable mechanical device (example code listed under transplant services) |
| 43882 | Neurostimulator-related code listed in document |
| 61863 | Neurosurgical device implantation code |
| 61864 | Neurosurgical device implantation code |
| 61867 | Neurosurgical stimulation code |
| 61868 | Neurosurgical stimulation code |
| 61885 | Neurosurgical code |
| 61886 | Neurosurgical code |
| 63650 | Spinal neuromodulation code |
| 63655 | Spinal neuromodulation code |
| 63685 | Neurostimulator lead implantation |
| L8682 | Implantable device coding (HCPCS) |
| L8685 | Implantable device coding (HCPCS) |
| L8686 | Implantable device coding (HCPCS) |
| 32851 | Thoracic surgery/transplant related |
| 38232 | Stem cell procurement (note: authorization conditional) |
| J3391 | Drug HCPCS listed in transplant section |
| J3392 | Drug HCPCS listed in transplant section |
| J3394 | Drug HCPCS listed in transplant section |
| Q2041 | Product HCPCS listed |
| Q2042 | Product HCPCS listed |
| E2402 | Wound VAC device |
How to Request Authorization and Provider Responsibilities
How to request prior authorization
To request prior authorization submit online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com) or call 800-445-1638.
Drug prior authorization submission
For specified drugs (colony-stimulating factors, pegfilgrastim products, denosumab, etc.) submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.
Cardiology prior authorization
Cardiology outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echoes require prior authorization; submit requests via the Provider Portal or call 866-889-8054.
DME prior authorization and vendor routing
Prior authorization is required for numerous DME codes listed; request DME items through Preferred Homecare at 800-636-2123; for items not provided by Preferred Homecare follow the contracted vendor list in the UnitedHealthcare Provider Manual at UHCprovider.com/AZcommunityplan.
Enteral/parenteral prior authorization and documentation
Enteral and parenteral services require clinical documentation and the Certificate of Medical Necessity as applicable; request services and supplies through Preferred Homecare.
Age-specific prior authorization guidance
For members younger than 21, follow AHCCCS AMPM Chapter 400, Section 430 (EPSDT) for prior authorization requirements and certificates of medical necessity; for members 21 and older refer to AMPM Chapter 300, Policy 310-GG.
Experimental/investigational and genetic testing prior authorization
Experimental/investigational services and listed genetic/biomarker procedures require prior authorization; contact the referenced labs or submit requests via the prior authorization channels provided.
Hearing services authorization rules by age
Hearing evaluations and hearing aids for members younger than 21 do not require prior authorization; for members 21 and older prior authorization is required when medically necessary.
Infusion in-home services prior authorization contact
Prior authorization is required for infusion in-home services not covered by Optum Infusion; to request services and supplies call Optum Infusion at 888-705-4470.
Injectable medications requiring prior authorization (listed codes)
A lengthy list of injectable medications and their HCPCS/J-codes are listed as requiring prior authorization; providers must reference the specific code list when submitting requests.
Hearing services PA notes for members <21
Certain hearing evaluation and hearing-aid related V-codes for members younger than 21 are listed and prior authorization is not required for those evaluations; other V-codes have varied prior authorization notes.
Out-of-network prior authorization
Prior authorization is required for all out-of-network services.
Therapy prior authorization rules
For members younger than 21, occupational and physical therapy are covered when medically necessary and require prior authorization after the initial evaluation and before the initial therapy visit and for ongoing visits; for members 21 and older prior authorization is not required for occupational and physical therapy.
Medication prior authorization requirements
A list of medications requiring prior authorization is available at UHCprovider.com/AZcommunityplan (Pharmacy Resources and Physician Administered Drugs); service requests must include 'J' Codes and NDC Codes for the medication requested.
Pharmacy prior authorization contact
For pharmacy prior authorization contact UnitedHealthcare Pharmacy Prior Authorization Service by phone 800-310-6826 or fax 866-940-7328; specialty pharmacy prior authorization fax submissions use 866-940-7328 and forms are available on the provider website.
Prior authorization overview and contacts
Prior authorization is not required for occupational and physical therapy for members 21 and older; for members younger than 21 speech therapy is covered when medically necessary but prior authorization is required after the initial evaluation and before the initial therapy visit and for ongoing visits. Advanced outpatient imaging and proton beam therapy also require prior authorization via the Provider Portal or by phone 866-889-8054.
Procedure-specific prior authorization (pregnancy termination, private-duty nursing, prostate)
Prior authorization is required for pregnancy termination (including mifepristone/Mifeprex®) and must include clinical documentation and the Certificate of Medical Necessity; private-duty nursing and listed prostate procedure codes also require prior authorization.
Site of service (SOS) prior authorization rules
Some services require prior authorization only when performed in an outpatient hospital setting (Site of Service - SOS outpatient); providers should request prior authorization for those services when scheduled in an outpatient hospital.
Skilled nursing facility prior authorization
Prior authorization is required for the listed skilled nursing and skilled nursing facility service codes.
Durable medical equipment / specialty beds and stimulator implantation
Prior authorization is required for listed specialty/enclosed beds and related HCPCS codes (E0250–E0316, etc.); stimulator implantation codes are also flagged as requiring prior authorization.
Transplant and CAR T-cell therapy prior authorization and case management
Transplant services and CAR T‑cell therapy require prior authorization and clinical documentation to establish medical necessity; contact the UnitedHealthcare Community and State Transplant Case Management Team at the phone number listed in the document.
Sterilization procedures prior authorization and consent
Prior authorization is required for the listed sterilization procedure codes; any member requesting sterilization must sign the appropriate Consent for Sterilization form.
Spinal surgery prior authorization
Prior authorization is required for the extensive list of spinal surgery and neurosurgery CPT codes shown in the document.
Transplant and CAR T-cell therapy prior authorization contact
For transplant and CAR T‑cell therapy services (including listed agents such as Abecma, Breyanzi, Carvykti, Kymriah, Yescarta, etc.) contact the UnitedHealthcare Community and State Transplant Case Management Team at the phone number provided in the document.
Transportation prior authorization and scheduling
To schedule non-emergent transportation (taxi and stretcher van) call Medical Transportation Management (MTM) at 888-700-6822; prior authorization is required.
VAD notification and prior authorization process
For Ventricular Assist Devices (VAD) prior authorization/notification: call the notification number on the back of the member's health plan ID card, then fax the nurse‑provided form to the Optum VAD Case Management Team at 855-282-8929.
Wound vac prior authorization
Wound VAC device (E2402) requires prior authorization for the listed code.
Definitions and Terms
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