Prior authorization requirements for Florida Medicaid
Lists prior authorization requirements for inpatient and outpatient services for providers participating with UnitedHealthcare Community Plan in Florida; explains how to request prior authorization and notes exceptions for emergency/urgent care and out-of-network providers.
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Florida Medicaid
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateAug 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210.
No material clinical or coverage changes in this revision.
2024-08-01effective date
Portalsubmit method
877-842-3210phone
manyPA required
$500DME threshold
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listed
Investigational codes
Services Requiring Prior Authorization
Coverage criteria examples
Services listed require prior authorization unless noted (for example, emergency or urgent care). Representative service groups and example codes include:
ALL of the following
CPT/HCPCS codes: 97810, 97811, 97813, 97814
ALL of the following
CPT codes: 43644, 43645, 43659, 43770
ALL of the following
See member ID card referral number for plan-specific codes
Injectable chemotherapy (outpatient) — prior authorization required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis
Fragments containing template or placeholder entries for HCPCS/CPT codes and prior authorization fields; no actionable coverage criteria appear in these lines.
Template / placeholder entries referencing HCPCS codes and product names (e.g., J1558, J0218, Xenpozyme, Xembify, Xolair) — no operational PA instructions provided in these fragments
Prior authorization requirements (partial)
Selected services and codes in this segment that require prior authorization:
ALL of the following
Example CPTs referenced for joint replacement and related procedures (document lists multiple procedure codes)
Outpatient therapy authorization requirements and submission expectations:
ALL of the following
Requests must be submitted by a primary care provider via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com)
ALL of the following
For certain outpatient therapy codes, call OptumHealth Physical Health at 800-873-4575 or use the notification number on the member's ID card
Place of Service exception — prior authorization not required when Place of Service is Home/12/Bill for specified codes
Radiation therapy prior authorization
Radiation therapy services that require prior authorization:
ALL of the following
Example CPTs: IMRT-related 77385 (and 77386), proton beam 77520-77525
Definition: Proton beam — focused radiation therapy using beams of protons
Providers must notify prior to scheduling and submit requests via the Provider Portal or call the designated phone number
Surgery, device implantation, transplant and CAR T authorization criteria
Surgery, device implantation, transplant and CAR T authorization criteria:
ALL of the following
Examples: rhinoplasty/septoplasty (30400–30465), shoulder surgery (29805–29827), sinuplasty (31295–31298), spinal procedures and stimulators (specific CPTs listed in document)
ALL of the following
Prior authorization contact: UnitedHealthcare Community and State Transplant Case Management at 888-936-7246
Stimulators and certain device implantations (including VADs) — prior authorization required and may require specific notification/fax workflows
Prior authorization criteria (segment)
Additional prior authorization requirements and contact instructions for selected services:
Transplant and CAR T‑cell therapies — prior authorization required; call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246
Operational step: call the notification number on the back of the member's ID card and fax the nurse‑provided form to Optum VAD Case Management at 855-282-8929
Code 38232 — prior authorization only for oncology indication
CPT / HCPCS / ICD-10 Codes Referenced
Covered CPT Codes - Bone growth stimulator / Radiation therapyCPTCovered
20975
Electrical stimulation for treatment, noninvasive (bone growth stimulator)
20979
Ultrasound bone growth stimulator
77401
Radiation therapy planning, simple
77402
Radiation therapy planning, intermediate
77407
Radiation therapy planning, complex
77412
Radiation therapy plan, other/complex
77385
Proton beam, simple, per treatment or fraction
77386
Proton beam, complex, per treatment or fraction
77520
Proton treatment delivery, per treatment session
77521
Proton planning (if applicable) - (note: related proton codes included)
1–10 of 14
1/2
Covered CPT Codes - Non-mastectomy breast reconstructionCPTCovered
19316
Mastopexy (breast lift) — used in reconstruction contexts
19318
Reduction mammoplasty (breast reduction) — when reconstructive
Unclassified code - see policy for product-specific PA requirements
C9149
Temporary code example
C9151
Temporary/unclassified code example
C9166
Temporary code example
C9399
Unclassified HCPCS
J3490
Unclassified drug code
J3590
Unclassified vaccine code
J3399
Zolgensma listing
J0218
Xenpozyme alternate listing
How Providers Request Prior Authorization and Notification
Prior Authorization
How to request prior authorization and exceptions
To request prior authorization or provide required notifications, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the numbers below. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all non-emergent procedures and services.
Use portal tile: Prior Authorization and Notification
Emergency/urgent care: no prior authorization required
Some services require provider or laboratory-to-payer notifications (see genetic/molecular testing)
Prior Authorization
Examples of services and codes requiring prior authorization
Representative examples of services that require prior authorization. This list highlights commonly required procedures and representative CPT/HCPCS/J-codes — always check the portal or call for the full, up-to-date code list for a specific member.
Site of service rules: PA required for certain outpatient hospital settings; not required if Place of Service = Home (12)
Key Terms and Definitions
Prior authorization — definition and submission methods summary
DefinitionPrior authorization is the process by which providers must request approval from UnitedHealthcare before performing certain inpatient or outpatient services.
Online submissionSubmit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).
Phone submissionCall 877-842-3210 to request prior authorization if not using the portal.
ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network providers must still request PA for non-emergent services.
Cochlear implants and other auditory implants — definition
DefinitionCochlear implants and other auditory implants: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational hearing.
Document Dates and Change Log
Effective August 1, 2024effective_dateLatest
Policy effective date established (Prior authorization requirements for Florida Medicaid effective August 1, 2024).
revision_contact_change
Updated provider submission contact information and phone numbers for prior authorization and prior notification referenced throughout the document (portal and phone contacts e.g., 877-842-3210 and 888-397-8129).
Policy Summary
PayerUnitedHealthcare
PolicyPrior authorization requirements for Florida Medicaid
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateAug 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210.
Enteral and in‑home nutritional therapy (including enteral formulas and related supplies) require prior authorization. Representative HCPCS codes are listed below — confirm specifics and quantity/duration via the portal.
Prior authorization required for enteral/in‑home nutritional therapy services
Submit estimated supplies, formula type, diagnosis, and anticipated duration with the PA request
Prior Authorization
DME prior authorization and cost threshold
Durable medical equipment (DME) and orthotics/prosthetics require prior authorization when the retail purchase or cumulative rental cost exceeds $500. Some specified orthotics/prosthetic codes and many listed DME items are subject to PA.
PA required when retail purchase or cumulative rental > $500
Prosthetics are not categorized as DME for the $500 threshold in some cases; verify via portal
Some home health services may qualify but are not subject to the cost threshold
Services and codes flagged as experimental, investigational, or linked to investigational therapies require prior authorization. The insurer may deny coverage for non‑covered experimental procedures.
Prior authorization required for investigational and linked services
Unclassified and temporary codes (C/TC codes and J3490/J3590) require PA only for specific products (e.g., Nulibry™, Rivlofza, Vabysmo™) — check Review at Launch guidance
Prior Authorization
Injectable medications prior authorization
Many injectable medications and biologics require prior authorization. The list below consolidates representative J-/Q-/A‑codes and product names commonly requiring PA — this is not exhaustive; use the portal or drug‑specific policies for clinical criteria.
Large molecule therapies, enzyme replacements, monoclonal antibodies, gene therapies, CAR‑T, and many specialty injectables require PA
Unclassified/temporary codes and J3490/J3590 entries are subject to PA rules when used for certain new therapies — see Review at Launch and product lists
Some drugs require prior notification through OptumRx (e.g., Cimzia, Synagis, Xolair)
Note
General information — codes list (partial) and new‑drug handling
General coding and drug information highlights: policy references include a partial code list (CPT/HCPCS/J codes) for products that require prior authorization and notes about special handling for newly launched drugs.
The source includes repeated mentions of J1558 / Xembify and J1558 / Xenpozyme entries — these product-code pairs are subject to PA
Unclassified and temporary codes (C9090, C9094, C9151, C9157, C9166-9168, C9399, J3490, J3590) are reviewed for specific marketed products
Pre-determination is recommended for newly launched drugs on the Review at Launch list
Note
General information — Stelara / Sublocade and assorted products
Specific product and HCPCS/J-code references called out in the source are included here for provider awareness — verify exact PA requirements and clinical criteria in the portal or associated drug policy.
Repeated entries in the source associate Tezspire and J3241 — confirm correct J-code mapping on the portal (Tezspire is product of interest and often subject to PA)
Stelara and Sublocade appear with J3358 / Q9991 references; PA and special program notes may apply
Prior Authorization
Injectable medications (cont.) and unclassified/temporary codes
The injectable medications listing continues with many specialty and high‑cost agents; unclassified/temporary codes and C‑codes appear for newly coded therapies. Always include NDC/product identifiers and clinical indication when submitting PA for these agents.
Unclassified/temporary and C-codes in the list (e.g., C9090, C9166–C9168) require special review
When using J3490/J3590 or other unclassified codes, include product name, NDC, and clinical rationale to avoid delays
Documentation Required
Specific drug codes and temporary/unclassified codes
The source contains specific drug-code mappings and temporary/unclassified code calls — examples below illustrate mappings and PA expectations. For some novel therapies the payer has designated specific C- or temporary codes; these require case-by-case review.
Prior authorization is required for many agents billed under temporary or unclassified codes; include supporting clinical documentation
Check Review at Launch list and the portal for most current code mappings
Prior Authorization
Tezspire / J3241 references
Tezspire references and J3241 appear repeatedly in the source. Providers should confirm the correct J‑code for Tezspire and submit PA with product-specific documentation and diagnosis indications.
Multiple repeated mentions indicate a review requirement for Tezspire — submit clinical rationale, prior therapy history, and NDC/product details
Documentation Required
HCPCS / J-code mapping and unclassified code guidance
Some HCPCS-to-product mappings and J-code cross-references are present in the source (including multiple entries for J3490 and C-codes). When billing insert the precise J- or HCPCS code and include product name and NDC for specialty agents.
For C-codes and J3490, include manufacturer, product name, NDC, and indication on the PA to expedite review
When mappings are ambiguous (repeated entries), rely on portal guidance and Review at Launch resources
Prior Authorization
Intravitreal VEGF and related J-codes
Intravitreal VEGF therapies and related ophthalmology injectables require prior authorization. Representative J-codes used for anti‑VEGF and related intravitreal agents are shown — confirm exact product-to-code mapping when submitting a PA.
Include ophthalmic diagnosis, prior response to therapy, and suggested treatment plan with PA
Some intravitreal products have product-specific criteria — verify in the portal
Documentation Required
Repeated J1558 / Xembify entries
The source repeatedly references J1558 and Xembify/Xenpozyme entries. These repeated mentions indicate special handling — include the drug name, NDC, dose, and clinical justification when submitting prior authorization requests for these products.
Repeated product-code pairs (J1558 / Xembify / Xenpozyme) should be validated in the portal and via drug-specific policies prior to submission
Provide exhaustive documentation for enzyme replacement or infusion therapies to avoid delays
Documentation Required
General HCPCS prior authorization placeholders
General HCPCS placeholders and common prior authorization patterns are used across the policy (J1558, J0218 and other placeholders appear). When a placeholder code is used, always attach product identifiers and the clinical rationale to the PA.
Attach manufacturer/product name, NDC, supporting clinical data, and intended dosing schedule if using placeholder or unclassified codes
Review at Launch and the portal provide updated mappings for placeholders as products receive permanent codes
Prior Authorization
Advanced outpatient imaging prior authorization process
Care providers ordering advanced outpatient imaging (CT/MRI/MRA/PET and certain nuclear medicine procedures) are required to provide notification prior to scheduling and obtain prior authorization where indicated. Use the Provider Portal or call the dedicated imaging number.
Notification prior to scheduling is the provider's responsibility
For PA submit via Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054
Prior Authorization
Ventricular assist devices (VAD) prior authorization / notification process
Ventricular assist devices (VAD) require notification and prior authorization. Providers should call the notification number on the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management team.
After the call, fax the completed form provided by the nurse to 855-282-8929
Prior Authorization
Vein procedures prior authorization
Vein and venous procedures (including removal/ablation of saphenous trunks and branches) require prior authorization. Submit PA with relevant duplex imaging, clinical history, and treatment plan.
Include clinical documentation such as ultrasound/duplex results and conservative management attempts
If device or advanced modality is planned, include device details and site-of-service justification
PA requirementPrior authorization required for cochlear implants and related auditory implant devices.
Example codesExample CPT/HCPCS codes listed include 69710, 69714, 69930 and device codes L8619, L8690, L8691, L8614, L8692.
Inpatient video EEG — definition and code range reference
DefinitionInpatient video EEG (cerebral seizure monitoring) — inpatient video electroencephalogram specified by CPT codes in the 95700–95726 range.
PA requirementPrior authorization required for inpatient video EEG services.
Example CPT codesCodes shown include 95700, 95714, 95715, 95720, 95722, 95724, 95726.
Durable Medical Equipment (DME) — definition and PA nuance for specific codes
DefinitionDurable Medical Equipment (DME) — equipment items listed in the document for which prior authorization is required only for the specific codes shown.
PA nuance — cost thresholdSome DME items require prior authorization when retail purchase or cumulative rental cost exceeds $500 (see specific HCPCS codes listed).
Prosthetics noteSome prosthetics are not considered DME and are noted as exempt in the DME section.
Experimental/Investigational — definition and PA implication
DefinitionExperimental/Investigational services — specific CPT/HCPCS codes flagged as experimental or investigational in the document require prior authorization.
PA implicationCodes designated as investigational/linked services (examples include 33477, 36514, 64722, 65765, 0191T) are listed as requiring prior authorization.
Provider actionRequests for these investigational services must follow the standard prior authorization submission process.
DefinitionEnteral services / In-home nutritional therapy — nutritional therapy delivered enterally or orally in the home setting.
PA requirementPrior authorization is required for listed enteral and in-home nutritional therapy codes (e.g., B4034, B4035, B4036, B4100).
ScopeApplies to enteral formula and related home nutrition services as shown in the HCPCS code list.
Laboratory notification process for genetic/molecular testing
Process summaryFor genetic and molecular testing where sequencing is performed, the ordering provider must notify the laboratory conducting the test and the laboratory will notify UnitedHealthcare.
PA requirementNumerous molecular and genetic CPT/HCPCS codes require prior authorization (examples include 87505, 87506, 87507, 0006M, 0007M, 0012U).
Provider responsibilityEnsure the laboratory has been notified so the lab can notify UnitedHealthcare per the instruction in the genetic testing section.
Somatuline Depot — product reference within code listings
Product mentionSomatuline Depot is referenced multiple times in the injectable/product listings within the document.
ContextSomatuline Depot appears alongside other product and HCPCS/J-code entries in code lists, indicating it is among products tracked for prior authorization.
ActionTreat Somatuline Depot entries per the document's prior authorization submission instructions when applicable.
Tepezza — product name linked to J3241 in listings
Product-code linkTepezza is repeatedly listed in the document and is linked with HCPCS code J3241.
Listing contextTepezza/J3241 appears multiple times in the general information/code lists implying prior authorization mapping in the policy.
Provider actionFollow standard prior authorization submission for requests involving Tepezza (J3241) as indicated by code lists.
Unclassified and temporary codes — C9xxx and temporary codes definition
DefinitionUnclassified and temporary codes (C9xxx and other temporary codes) are used for new or unclassified injectable medications and appear in the injectable medication listings.
PA noteFor certain unclassified/temporary codes prior authorization is only required for specific products (document cites examples and treatment guidance).
ExamplesDocument references C9090, C9094, C9149, C9151, C9166, C9167, C9168 and other unclassified/temporary codes in the injectables section.
Intravitreal Vascular Endothelial Growth Factor (VEGF) — definition and code group
DefinitionIntravitreal Vascular Endothelial Growth Factor (VEGF) — category of ophthalmologic injectable agents used intravitreally.
Example J-codesAssociated J-codes listed include J0178, J0179, J2777, J2778, J2779.
PA contextThese intravitreal VEGF agents are included in the injectable medication lists subject to prior authorization per the document.
Intravitreal VEGF (alternate entry)
Alternate entryIntravitreal VEGF is reiterated in the document as a labeled group for injectable ophthalmologic agents.
Provider noteFollow prior authorization process for these intravitreal VEGF codes as shown in the injectables section.
Xenpozyme — product mention associated with J1558
Product mentionXenpozyme is referenced in association with HCPCS code J1558 in repeated general-information template entries.
Listing behaviorJ1558 appears repeatedly with product names Xembify/Xenpozyme indicating these products are tracked in the policy's code lists.
PA implicationFollow the document's prior authorization submission instructions for requests involving J1558/Xenpozyme when applicable.
Xembify — product mention alongside placeholder PA fields
Product mentionXembify is repeatedly listed alongside HCPCS code J1558 in template-like code entries.
ContextEntries for Xembify/J1558 appear with placeholder prior-authorization fields, suggesting PA applies per policy mapping.
Provider actionSubmit prior authorization per the portal/phone instructions when requesting services billed with J1558/Xembify.
Prior notification (OptumRx) — definition and context
DefinitionPrior notification (OptumRx) — a process for certain drugs where prior notification is obtained through OptumRx Prior Notification Services.
Phone contactOptumRx Prior Notification Services phone number provided: 800-310-6826 (for Cimzia, Synagis, Xolair prior notification per document).
ContextThe document differentiates prior notification (OptumRx) from standard prior authorization submission via UnitedHealthcare portal/phone.
Orthotics and Prosthetics PA threshold — definition
Threshold definitionOrthotics and prosthetics require prior authorization only for codes listed when retail purchase or cumulative rental cost is more than $500.
ExamplesSample L-codes cited include L0170, L0456, L0462, L0480, L0624, L3901, L5050 and others in the orthotics/prosthetics lists.
Provider actionObtain prior authorization for orthotics/prosthetics that meet the >$500 retail purchase or cumulative rental threshold.
Proton beam definitionProton beam — focused radiation therapy that uses beams of protons (tiny particles with a positive charge); listed codes include 77520 and related series.
PA requirementRadiation therapy types including IMRT and proton beam require prior authorization per the document.
Duplicate token noteProton beam focused radiation therapy is defined in the document as focused radiation using proton beams; related CPT codes include 77520–77525.
PA implicationPrior authorization is required for proton beam therapy services per the radiation therapy section.
Example codesExamples include CPT codes 77520, 77522, 77523, 77525 and 77385 (IMRT).
Advanced outpatient imaging — CT, MRI, MRA, PET and nuclear procedures requiring PA
DefinitionAdvanced outpatient imaging — certain CT, MRI, MRA, PET scans and nuclear medicine/nuclear cardiology procedures that require prior authorization.
Provider notificationCare providers ordering these procedures must notify prior to scheduling and submit PA requests via the UnitedHealthcare Provider Portal or call 866-889-8054.
ScopeFor CPT codes requiring PA and full details visit UHCprovider.com/FLcommunityplan as noted in the document.
Ventricular assist devices (VAD) — definition and PA/notification context
DefinitionVentricular assist devices (VAD) — a mechanical pump that takes over the function of a damaged ventricle and restores normal blood flow.
PA/notification processPrior authorization/notification required; call the notification number on the back of the member's health plan ID card and fax required form to Optum VAD Case Management at 855-282-8929.
Provider actionFollow the member-ID-directed contact method and fax instructions for VAD case management per the document.