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Prior Authorization Requirements — UnitedHealthcare Community Plan of Arizona Long Term Care
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Governs prior authorization requirements and submission methods for health care professionals participating with UnitedHealthcare Community Plan of Arizona Long Term Care for inpatient and outpatient services in Arizona.
Policy Summary
PayerUnitedHealthcare
PolicyPrior Authorization Requirements — UnitedHealthcare Community Plan of Arizona Long Term Care
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionRequest prior authorization via the Prior Authorization and Notification tool on UHCprovider.com or call 877-842-3210.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Online & phonemethods to request prior authorization
AHCCCSservices must be covered per
Prior auth requiredinpatient admissions
Routine circumcisioncoverage exclusion noted
4distinct ICD-like codes repeated
Coverage criteria, exceptions, and required authorizations
Non-emergent air ambulance authorization criteria
Non-emergent air ambulance services require prior authorization. The following summarizes the authorization requirement and the HCPCS codes to which it applies.
ALL of the following
- Prior authorization is required for non-emergent air ambulance services for covered members.
Requests must include clinical documentation supporting medical necessity and justification that ground transport is not appropriate due to the member's medical condition.
Affected HCPCS codes
- A0430 - Air ambulance, transport, one way, fixed wing aircraft, local or nonurbanHCPCS
- A0431 - Air ambulance, transport, one way, rotary wing aircraft, medical serviceHCPCS
- A0435 - Air ambulance, fixed wing, transport and/or services providedHCPCS
- A0436 - Air ambulance, rotary wing, transport and/or services providedHCPCS
- Prior authorization processes and contact information: follow payer-specific prior authorization submission channels; include transport origin/destination, clinical condition, and why non-air alternatives are not clinically appropriate.
Failure to obtain prior authorization may result in denial or reduced reimbursement.
Codes and coding rules that trigger prior authorization
Sample codes requiring prior authorizationCPT | HCPCSCovered
| 92607 | Augmentative and alternative communication assessment/provision |
| A9901 | Augmentative/alternative communication device or service (HCPCS) |
| 20975 | Electrical stimulation/ultrasound for bone healing |
| 19330 | Breast reconstruction (example) |
| 37220 | Endovascular revascularization (example cardiovascular code) |
| 37230 | Transcatheter embolization/other vascular intervention (example) |
Repeated ICD-like codesICD-10
| E08.52 | Listed in document fragment |
| E09.52 | Listed in document fragment |
| E10.52 | Listed in document fragment |
| E11.52 | Listed in document fragment |
Injectable medication J-/Q-codes requiring prior authorization (partial list)HCPCS | NDC | mixed
| J0567 | Briumvio (listed) |
| J2329 | Briumvio (alternate listing) |
| J0741 | Cabenuva (listed) |
| Q5128 | Cimerli (listed) |
| J2786 | Cinqair (listed) |
| J0802 | Cortrophin Gel (listed) |
| J0584 | Crysvita (listed) |
| J1551 | Cutaquig (listed) |
| J1413 | Elevidys (listed) |
| J2508 | Elfabrio (listed) |
1–10 of 11
1/2
Listed injectable drug codes and unclassified codesmixed
Injectable and temporary codes referencedHCPCS
| J0178 | Example injectable HCPCS code listed in document |
| J0179 | Example injectable HCPCS code listed in document |
| J2778 | Example injectable HCPCS code listed in document |
| J1322 | Example injectable HCPCS code listed in document |
| J3032 | Example injectable HCPCS code listed in document |
| J9332 | Vyvgart listed |
| Q5124 | Example HCPCS code listed |
| J9334 | Vyvgart/Hytrulo listed |
| J1558 | Xembifye listed |
| J0218 | Xenpozyme—authorization prior required (see Review at Launch) |
1–10 of 12
1/2
Orthopedic procedure codes referencedCPT
| 24360 | Joint replacement code listed |
| 24370 | Joint replacement code listed |
| 27120 | Total hip replacement code listed |
| 27125 | Total hip replacement code listed |
| 27132 | Knee replacement code listed |
| 27134 | Knee replacement code listed |
| 27137 | Knee replacement code listed |
| 27412 | Knee replacement procedure requiring prior auth |
| 27446 | Knee replacement procedure requiring prior auth |
| 27447 | Knee replacement procedure requiring prior auth |
1–10 of 13
1/2
Non-emergent air ambulance HCPCS codes requiring prior authorizationHCPCSCovered
inv-35: DME prior authorization threshold — $500 retail purchase or cumulative rental cost
DME prior authorization thresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $500.
ScopeApplies to listed DME HCPCS codes; Arizona Long‑Term Care will review Medicare denials of DME.
ReferenceSee AMPM Chapter 300: Medical Policy for Covered Services > 310 for related policy guidance.
inv-36: Incontinence supplies monthly quantity threshold — 240 (<21), 180 (>=21)
Incontinence supplies threshold for <21Prior authorization required when requests exceed 240 briefs/diapers per month (includes pull-ups).
Incontinence supplies threshold for 21+Prior authorization required when requests exceed 180 briefs/diapers per month (includes pull-ups).
ScopeApplies to incontinence briefs and diapers including pull-ups for member age groups as specified.
How providers request authorization, submission channels, and operational contacts
Prior Authorization
How to request prior authorization
This list contains prior authorization requirements for UnitedHealthcare Community Plan of Arizona Long Term Care. Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID) or by phone at 877-842-3210.
- Services must be covered benefits per AHCCCS to be eligible for authorization.
- Experimental/investigational services are not covered.
- Out-of-network/out-of-state services require authorization and supporting documentation.
- All rendering providers, facilities and vendors must be actively registered with AHCCCS.
- Only medically necessary, cost-effective, federally- and state-reimbursable services per AHCCCS are covered.
- Only a health care professional may request authorizations.
Documentation Required
Eligibility and requester requirements
Providers: authorizations may only be requested by a health care professional and services must be covered under AHCCCS. Ensure the rendering provider/facility/vendor is actively registered with AHCCCS and include documentation to establish medical necessity when required.
- Eligibility: Services must meet AHCCCS coverage definitions.
- Requester: Only health care professionals may submit authorization requests.
Documentation Required
Authorization code fragments and notes
Authorization code fragments E08.52, E09.52, E10.52, E11.52 are referenced in the source as diagnosis code entries; include the full ICD-10 when submitting supporting documentation. When unclassified/temporary HCPCS/CPT codes are used (for example C9151, C9399, C9157, C9160–C9162, J3490, J3590), follow Review at Launch guidance — pre-determination is highly recommended for new-to-market medications.
Prior Authorization
Cerebral seizure monitoring / Inpatient video electroencephalogram (EEG)
Inpatient video electroencephalogram (video EEG) services require prior authorization for many inpatient codes; some inpatient EEG codes are not required for authorization. Confirm code-specific requirements before scheduling.
- Prior authorization required for inpatient video EEG codes: 95700, 95711, 95712, 95713.
- Prior authorization not required for code: 95714 (per source statement).
- Additional inpatient/outpatient EEG related codes referenced: 95715, 95716, 95718, 95720, 95722, 95724, 95726 — verify authorization requirement per each code prior to service.
Prior Authorization
Enteral/Parenteral/Oral nutrition and related supply codes
Enteral, parenteral (TPN) and commercial oral nutritional supplements and related supplies require prior authorization. For in‑home nutritional services and TPN administered via gastrostomy tube or IV, include clinical documentation and a Certificate of Medical Necessity when applicable.
- Enteral/parenteral/oral HCPCS codes requiring authorization: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B9002, B9998, B4161.
- In‑home nutritional (TPN) HCPCS: B4150, B4152, B4153, B4155.
- Certificate of Medical Necessity for Commercial Oral Nutritional Supplements: see AHCCCS AMPM Chapter 400/430-2 (members <21) and AMPM Chapter 300/310-GG (members 21+).
- Clinical documentation to establish medical necessity must accompany requests; for members <21, follow EPSDT guidance where applicable.
Documentation Required
In‑home nutritional / TPN prior authorization and documentation
Total parenteral nutrition (TPN), lipids and related in‑home nutritional services require prior authorization with supporting clinical documentation. For pediatric members review AMPM Chapter 400 (Policy 430-10) and for adults AMPM Chapter 300 (Policy 310-GG).
Prior Authorization
Surgical procedure prior authorization (FAI, FESS)
Certain surgical procedures require prior authorization. For femoroacetabular impingement (FAI) and functional endoscopic sinus surgery (FESS), obtain authorization before elective scheduling.
Prior Authorization
Hospice prior authorization contact and code list
Hospice services require prior authorization through the Long‑Term Care Case Management Unit. Call the unit to obtain authorizations and to submit required hospice requests; infusion services delivered under hospice may have separate guidance.
- For hospice prior authorization and to complete hospice requests call Long‑Term Care Case Management Unit at 602-255-8908.
- Hospice‑related HCPCS/CPT codes referenced for authorization processing include: G0299, G0300, S9123, S9124.
- For some hospice/infusion services the source indicates infusion prior authorization may not be required — confirm per code and clinical circumstance when submitting.
Prior Authorization
Injectable medications prior authorization references
Many injectable and specialty medications require prior authorization. Use the UnitedHealthcare specialty medication submission paths on UHCprovider.com (Prior Authorization / Specialty Medications > Submission and Status) and contact Optime Specialty Guidance Program for assistance where indicated.
- Large list of injectable medications require prior authorization — examples from source: J3262 (Actemra), J0801 (Acthar), J0791, J0172 (Aduhelm), J1426, J0225 (Amvuttra), J0567 (Briumvio), J2329, J0741 (Cabenuva), Q5128 (Cimerli), J2786, J0802, J0584, J1551, J1413, J2508, J1302, J3380, J7204, J3111, J1305, J0517, J1951, Q0138, Q5130, J0222, J1576, J0897, J1304, J1301, J0896, J1745, Q5104, Q5123, J1412, J0596, J2998, J9333, J0491, J1747, S0013, J3358, Q9991, J1961, J2781, 90378, J3241, J2356, J3316, J1746, J9381.
- For commercial non‑PAR providers and specialty pre‑determination follow the online submission instructions at UHCprovider.com; for questions about the online authorization process call Optime Specialty Guidance Program at 877-881-7618.
- For new-to-market medications and unclassified/temporary codes (C9151, C9399, C9157, C9160–C9162, J3490, J3590) review the Review at Launch policy and consider pre‑determination.
Terms, thresholds, and contact references
inv-75: Services eligible for authorization must be covered benefits as defined by the Arizona Health Care Cost Containment System (AHCCCS).
AHCCCS-covered benefits requirementServices eligible for authorization must be covered benefits as defined by the Arizona Health Care Cost Containment System (AHCCCS).
Medical necessityOnly medically necessary, cost-effective, federally- and state-reimbursable services are covered.
Provider registrationAll rendering health care professionals, facilities and vendors must be actively registered with AHCCCS to request authorization.
inv-76: Services considered experimental and investigational are not covered benefits.
Experimental/investigational exclusionPrior authorization is required for all services considered experimental and/or investigational; such services are not covered benefits per AHCCCS guidance.
ReferenceSee AMPM Chapter 300, Section 320 (Policy 320-B) for details on experimental and investigational services.
Example codes notedDocument lists example codes associated with experimental/investigational items (e.g., A4638, 36514, A9274).
inv-77: authorization/code fragment — Document fragment repeatedly associates codes (E08.52, E09.52, E10.52, E11.52) with labels such as 'authorization' and 'CPT@ or HCPCS cod...'
Repeated code fragmentDocument repeatedly lists ICD-like codes E08.52, E09.52, E10.52, E11.52 in association with authorization notes and code references.
Nature of fragmentEntries present as authorization/code fragments linking those codes to CPT or HCPCS authorization lines without extended explanatory text.
ImplicationThese repeated fragments indicate those diagnosis codes appear in prior authorization context within the document.
inv-78: Prior authorization / Coverage status — Authorization required for certain inpatient services (e.g., inpatient EEG).
Inpatient authorization requirementPrior authorization is required for certain inpatient services (example: inpatient video EEG admissions require authorization).
Code-level variationSome EEG procedure codes are listed with mixed prior authorization status (some require authorization, others noted as not required).
ActionObtain prior authorization before inpatient EEG admissions when indicated by code guidance.
inv-79: authorization/code fragment — Document fragment repeatedly associates codes (E08.52, E09.52, E10.52, E11.52) with labels such as 'authorization' and 'CPT@ or HCPCS cod...'
Associated ICD-like codesE08.52, E09.52, E10.52, E11.52 are repeatedly associated with authorization entries in the document.
Labeling contextThese codes appear adjacent to phrases referencing CPT or HCPCS codes and instructions to obtain authorization.
No extended definitionThe document presents these as repeated fragments rather than full definitional text.
inv-80: Durable medical equipment (DME) prior authorization threshold — Applies when retail purchase or cumulative rental cost exceeds $500.
DME prior authorization thresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $500.
ApplicationApplies to the DME HCPCS codes listed elsewhere in the document; Arizona Long‑Term Care will review Medicare denials of DME.
Provider actionObtain prior authorization when the purchase or cumulative rental cost for DME items exceeds $500 before billing.
inv-81: Circumcision coverage — Routine circumcision is not a covered benefit; prior authorization only for documented medical necessity.
Circumcision coverage stanceRoutine circumcision is not a covered benefit under this plan.
Authorization exceptionPrior authorization is required only when circumcision is medically necessary and documented.
Relevant CPT codesCPT codes listed for circumcision include 54150, 54160, 54161, 54162 in the document.
inv-82: Certificate of Medical Necessity for Commercial Oral Nutritional Supplements — Location and reference to AHCCCS AMPM
Certificate of Medical Necessity locationThe Certificate of Medical Necessity for Commercial Oral Nutritional Supplements is available at azahcccs.gov under AHCCCS Medical Policy Manual (AMPM) Chapter 300/Chapter 400 references noted in the document.
AMPM referencesDocument references AMPM Chapter 300 (Policy 310-GG) and Chapter 400 for maternal/related guidance regarding oral nutritional supplements.
Use caseProviders should reference the AMPM and the Certificate when submitting prior authorization for commercial oral nutritional supplements.
inv-83: Case Management phone/fax for prior authorization (phone 602-255-8908; fax 877-395-5993)
Case Management phoneLong-Term Care Case Management Unit phone for prior authorization requests: 602-255-8908.
Case Management faxFax for Case Management prior authorization submissions: 877-395-5993.
Hospice/home health submission noteFor certain home health/hospice codes (e.g., G0299, G0300, S9123, S9124) providers should fax Case Management at 877-395-5993 to complete requests.
inv-84: Long-Term Care Case Management Unit contact — Phone number for prior authorization requests
Long-Term Care Case Management Unit phoneFor hospice and related prior authorization requests call the Long‑Term Care Case Management Unit at 602-255-8908 to complete the request.
Use for hospice codesThis contact is cited specifically for hospice-related codes including G0300, S9123, S9124.
Alternate submissionSome hospice/infusion items may have different requirements; follow Case Management guidance when in doubt.
inv-85: Optum Specialty Guidance Program (SGP) — Contact for questions about online authorization process
Optum SGP contactFor questions about the online authorization process, call the Optum Specialty Guidance Program (SGP) at 877-881-7618.
ContextReferenced in the injectable medications section as the contact for online prior authorization/submission questions.
Use caseProviders submitting specialty medication requests via UHCprovider.com may contact Optum SGP for assistance.
inv-86: Prior authorization submission portal — UHCprovider.com/priorauth Specialty Medications > Submission and Status
Submission portalSubmit prior authorization and pre-determination requests for specialty medications at UHCprovider.com/priorauth under Specialty Medications > Submission and Status.
ApplicabilityReferenced specifically for UnitedHealthcare commercial non-PAR health care professionals for specialty medication pre-determination/submission.
Provider actionUse the portal to submit and check status of prior authorization requests for listed injectable medications.
inv-87: Injectable medications entry — CPT or HCPCS codes and instructions on how to obtain prior authorization for listed injectable medications.
Injectable medications codes and instructionsPrior authorization is required for the injectable medication codes listed; the document includes multiple J-/Q-codes and instructs providers to use the portal or Optum SGP for submission.
ExamplesListed injectable examples include J3262 (Actemra), J0801 (Acthar), J0791 (Adakveo), J0218 (Xenpozyme) and many others shown in the injectable sections.
Review at Launch noteProviders are directed to the Review at Launch policy for newly approved drugs and pre-determination is highly recommended for drugs on that list.
inv-88: Review at Launch policy — Reference to Review at Launch for New to Market Medications
Review at Launch referenceCheck the Review at Launch for New to Market Medications policy at UHCprovider.com for up-to-date coverage and recommended pre-determination for newly approved drugs.
PurposeUsed to identify recently FDA-approved drugs that may require pre-determination and special authorization handling.
Provider actionPre-determine coverage for drugs on the Review at Launch Medication List when submitting authorization requests.
inv-89: Inpatient observation — Ordered in writing by authorized individual; prior authorization not required but notification required when admitted for observation.
Inpatient observation ordering and notificationInpatient observation must be ordered in writing by a physician or other individual authorized by hospital bylaws; prior authorization is not required but notification is required if member is admitted for observation.
DocumentationOrder must be in writing as per hospital staff bylaws to admit patients for observation status.
Provider actionNotify the plan when a member is admitted for inpatient observation per the document's notification requirement.
inv-90: Policy listing new FDA-approved drugs requiring review — Referenced for drugs with unclassified/temporary codes.
Review at Launch for new drugsPolicy lists newly FDA-approved drugs requiring review; providers should reference Review at Launch for medications with unclassified/temporary codes.
Unclassified/temporary codes noteFor codes such as C9151, C9399, C9149, C9157, C9160–C9162, J3490 and J3590, prior authorization applies only for a specific set of drugs identified in the document.
ActionFollow Review at Launch guidance and pre-determine when appropriate for drugs newly approved and listed.
inv-91: Non-emergent air ambulance — HCPCS codes A0430, A0431, A0435, A0436 identified as requiring prior authorization.
Non-emergent air ambulance HCPCS codesHCPCS codes A0430, A0431, A0435 and A0436 are identified as requiring prior authorization.
RequirementObtain prior authorization before billing these non-emergent air ambulance codes as the document reiterates prior authorization is required for the listed codes.
Repeated listingThese HCPCS codes are repeatedly listed across multiple sections indicating consistent authorization requirement.
inv-92: Musculoskeletal procedures — Example CPT codes (27487, 29866, 29867) identified as requiring prior authorization.
Musculoskeletal CPT examples requiring authorizationExample CPT codes requiring prior authorization include 27487, 29866 and 29867 (musculoskeletal procedures).
ScopePrior authorization is required for the musculoskeletal procedure codes listed in the document.
Provider actionObtain prior authorization for the listed musculoskeletal procedure CPT codes before scheduling/billing.
inv-93: Prior authorization — Prior authorization is required for the codes listed.
General prior authorization requirementPrior authorization is required for the specific codes listed throughout the document; providers must obtain authorization prior to service for those codes.
Code-level citationsThe document lists many CPT/HCPCS codes (examples across sections include injectable J-/Q-codes, hospice codes, DME codes, musculoskeletal and air ambulance codes) that require prior authorization.
Provider actionFollow code-specific guidance and use UHCprovider.com/priorauth or contact listed case management/Specialty Guidance contacts to submit requests.
inv-94: Non-emergent air ambulance — Repeated references and association with HCPCS codes requiring prior authorization.
Non-emergent air ambulance repeated requirementThe document reiterates that prior authorization is required for HCPCS codes A0430, A0431, A0435 and A0436.
ActionObtain prior authorization before providing or billing non-emergent air ambulance services using these HCPCS codes.
Location of referencesThese codes and the authorization requirement appear in multiple numbered sections of the document.
inv-95: Prior authorization requirement — General statement that prior authorization is required for the codes listed.
Prior authorization for listed HCPCS codesPrior authorization is required for the listed HCPCS codes (document explicitly names A0430, A0431, A0435, A0436).
Provider instructionInclude the appropriate HCPCS code on the prior authorization request and secure approval before service delivery.
Consistency noteMultiple document sections confirm the prior authorization requirement for these codes.
Policy Summary
PayerUnitedHealthcare
PolicyPrior Authorization Requirements — UnitedHealthcare Community Plan of Arizona Long Term Care
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionRequest prior authorization via the Prior Authorization and Notification tool on UHCprovider.com or call 877-842-3210.
SourceLink
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