CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for inpatient and outpatient services (UnitedHealthcare Community Plan of Hawaii)

Defines which procedures, services, diagnosis and CPT/HCPCS codes require prior authorization (or are exempt) for participating UnitedHealthcare Community Plan of Hawaii providers, and how to submit requests. Affects in-network and out-of-network providers serving plan members in Hawaii.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for inpatient and outpatient services (UnitedHealthcare Community Plan of Hawaii)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-980-8728.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

phone + onlinesubmission methods provided

exemptemergency/urgent exempt

Severalcategories require prior auth

Numerousdiagnosis codes listed no auth

Multiple

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device and supply codes

Coverage criteria and exemptions

Prior authorization-required codes

Prior authorization is required for the codes and services listed below unless otherwise noted. Codes are grouped by procedure/service type. When a code appears in multiple groups, the most specific prior authorization instruction applies. For questions or to submit a prior authorization request, use the UnitedHealthcare Provider Portal or the phone/fax instructions on the member's ID card.

Spinal surgery: Prior authorization required for the following CPT codes: 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22513, 22514, 22515, 22532, 22533, 22548, 22551, 22554, 22595, 22600, 22610, 22612, 22630, 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22849, 22852, 22855, 22856, 22861, 22899, 63001, 63003, 63005, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, 63047, 63050, 63055, 63056, 63064, 63075, 63077, 63081, 63102, 63170, 63172, 63173, 63250, 63251, 63252, 63265, 63267, 63268, 63270, 63271.

CPT, HCPCS and ICD-10 code groups

How providers submit requests and operational requirements

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (One Healthcare ID) or by phone at 888-980-8728. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care.

Prior Authorization

Outpatient injectable chemotherapy requires prior authorization

Injectable chemotherapy drugs administered in an outpatient setting require prior authorization; examples of listed HCPCS/J‑codes include A9590, A9607, A9699, J0640, J0641, J0642, J0897, J1442, J1447, J1448, J1449.

Prior Authorization

Procedure groups require prior authorization

Specific procedure groups are identified as requiring prior authorization; examples include bariatric surgery, bone growth stimulators, breast reconstruction and certain cardiovascular procedures with associated CPT codes provided in the listing.

Terms and quick references

inv-67: Prior authorization

DefinitionPrior authorization: Administrative approval process required before certain procedures or services are provided.

How to submitSubmit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at 888-980-8728.

Emergency carePrior authorization is not required for emergency or urgent care.

inv-68: Emergency/urgent care

DefinitionEmergency or urgent care services are exempt from prior authorization requirements.

Notification for inpatient emergenciesFor emergency inpatient admissions, the plan must be notified within 48 hours (see inpatient notification procedures).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for inpatient and outpatient services (UnitedHealthcare Community Plan of Hawaii)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-980-8728.

SourceLink

On This Page

Note

EEG codes exempt; outpatient chemotherapy requires authorization

Inpatient video EEG CPT codes (95720, 95722, 95724, 95726) are noted as prior authorization not required for outpatient hospital or ambulatory surgical center settings; concurrently, injectable chemotherapy administered in outpatient settings does require prior authorization.

Prior Authorization

Cochlear and auditory implants require prior authorization

Cochlear and other auditory implants require prior authorization; listed CPT/HCPCS examples include 69710, 69714, 69930 and L8614/L8619/L8690/L8691/L8692.

Prior Authorization

Continuous supplies require prior authorization

Continuous supplies are designated as prior authorization required; example HCPCS codes include A4226, A4239, A9276 and A9277.

Prior Authorization

Cosmetic and reconstructive procedures require prior authorization

Cosmetic procedures and many reconstructive procedure codes require prior authorization; numerous CPT/HCPCS codes are listed (examples include 11960, 14020, 15820, 17106 and others).

Prior Authorization

Enteral / in‑home nutrition requires prior authorization

Enteral/in‑home nutritional therapy requires prior authorization; multiple B4xxx HCPCS codes are listed (for example B4034, B4035, B4036, B4100, B4102, B4149, B4150, B4158, B4161). Experimental/investigational procedure codes in this segment also require prior authorization.

Prior Authorization

DME prior authorization exceptions and cost threshold

Certain DME codes are not subject to prior authorization unless specifically noted; some DME require prior authorization only when the retail purchase or cumulative rental cost exceeds $500. Examples of DME with conditional requirements include A9279, A9280, E0194 and E0265–E0277.

Documentation Required

Ordering incontinence supplies: call Medline

To request incontinence supplies (a covered benefit only when provided), providers or members should call Medline at 877-816-5587.

Prior Authorization

DME — incontinence supplies: benefit and how to request

Incontinence supplies are a benefit only when provided; to request incontinence supplies call Medline at 877-816-5587. Certain V52xx codes are listed as not requiring prior authorization.

Prior Authorization

Prior authorization required for enteral/in‑home nutritional therapy

Enteral/in‑home nutritional therapy lists multiple B4xxx HCPCS codes (including B4034‑B4036 and B4100‑B4161); prior authorization is required for these enteral services as listed.

Prior Authorization

Genetic and molecular testing requires prior authorization/notification

Genetic and molecular testing (including BRCA) requires prior authorization/notification for outpatient testing; ordering providers must complete the prior authorization/notification process and tests must be registered with the Genetic and Molecular Testing Prior Authorization/Notification Program. Example CPT codes include 81162, 81229, 81401, 81405, 81410, 87505 and others.

Prior Authorization

Hearing aids require prior authorization

Hearing aids and hearing aid services require prior authorization. Submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com), by phone at 888-980-8728, or by fax per the instructions in the document; example V‑codes listed include V5014, V5256 and V5254.

Prior Authorization

Home‑ and Community‑Based Services require prior authorization

Home‑ and Community‑Based Services require prior authorization for enumerated services (adult day programs, assisted living, attendant care, enteral nutrition, environmental modifications, home delivered meals, foster home, home health, incontinence supplies, nursing services, moving assistance, personal care services, PERS).

Prior Authorization

Home health prior authorization required in outpatient settings

Home health care prior authorization is required only in outpatient settings (to include the patient's home); multiple G‑codes (for example G0151, G0152, G0153, G0155) are listed for home health services.

Prior Authorization

Hospice prior authorization required only for inpatient settings

Hospice prior authorization is required only in inpatient settings; example codes include T2044 and T2045.

Note

SNF residents exempt from prior authorization

Members residing in a skilled nursing facility are exempt from prior authorization requirements per this section.

Prior Authorization

Injectable medications require prior authorization

A long list of injectable medications (many J‑ and Q‑codes) designated in Home‑and Community‑Based Services require prior authorization; examples include J3262, J0801, J0172, Q5121, J1551 and many others.

Prior Authorization

How to obtain prior authorization for injectable and unclassified codes

Submit prior authorization requests for injectable and unclassified/temporary codes online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888‑397‑8129. For unclassified/temporary codes C9399, J3490 and J3590, prior authorization is required only for specific drugs (Nulibry, Rivfloza, Steqeyma IV, Yesintek IV) — check the Review at Launch policy for updates.

Prior Authorization

Inpatient prior authorization and emergency admission notification

For emergency inpatient admissions notify UnitedHealthcare within 48 hours of admission. To request inpatient prior authorization, fax the member's registration/admission document with pertinent information (including date of service/admission) to UnitedHealthcare Community Plan of Hawaii at 800‑267‑8328. Routine obstetrics/deliveries require notification only.

Prior Authorization

Total hip and knee replacement require prior authorization

Joint replacement (total hip and knee) procedures require prior authorization; example CPT codes listed include 23470, 27130, 27447, 27120 and 27412.

Prior Authorization

Air ambulance transport requires prior authorization

Non‑emergent air ambulance transport requires prior authorization (example HCPCS codes S9960, S9961).

Prior Authorization

Off‑island travel requires prior authorization

Off‑island travel (including out‑of‑state travel) requires prior authorization; request online or by phone using the submission instructions on page 1 of the document.

Prior Authorization

Orthotics/prosthetics over $500 require prior authorization

Orthotics and prosthetics listed with a retail purchase or cumulative rental cost exceeding $500 require prior authorization; numerous L‑codes are enumerated (examples include L0112, L0170, L0456, L0462, L0480).

Prior Authorization

Orthognathic surgery requires prior authorization

Orthognathic surgery codes are listed and require prior authorization; examples include 21121, 21123, 21125, 21127 and extended code ranges through 21299.

Prior Authorization

Private duty nursing prior authorization required

Private duty nursing requires prior authorization only; codes T1002 and T1003 are listed.

Prior Authorization

Potentially unproven services require prior authorization

Services identified as potentially unproven require prior authorization; examples given include CPT/HCPCS codes 33289 and C2624.

Prior Authorization

Surgical and specialty procedures require prior authorization

Selected surgical and specialty procedures require prior authorization, including prostate procedures (37243, 52441–52442, 53850, 53852, 55873–55874), proton beam therapy (77520, 77522, 77523, 77525), rhinoplasty/septoplasty (30400–30435, 30462), sinuplasty (31295–31298), sleep apnea procedures (21685) and numerous spinal surgery CPTs.

Prior Authorization

Orthotics/prosthetics L‑codes require prior authorization

Extensive HCPCS L‑codes for orthotics/prosthetics are listed as requiring prior authorization within Home‑and Community‑Based Services (examples include L1840, L5795, L8040 and many others).

Prior Authorization

Spinal surgery requires prior authorization

Numerous spinal surgery CPT codes require prior authorization; examples include 22100–22102, 22110, 22513–22515, 22600, 22800–22819, 63001–63020, 63030–63081 and others listed throughout the spinal surgery section.

Prior Authorization

Select device codes require prior authorization

Prior authorization is required for select device codes; examples noted include CPT 63271 and HCPCS E0747 and E0748.

Prior Authorization

Stimulators and wound vac require prior authorization

Prior authorization is required for certain stimulators and wound vacuum devices; HCPCS examples include E0749, E0760 and E2402.

Out-of-network providersOut-of-network providers must request prior authorization for all procedures/services except emergent or urgent care.

inv-69: auditory implants

DefinitionAuditory implants: medical devices within the inner ear with an external portion to help persons with profound sensorineural hearing loss.

Prior authorization stanceCochlear and other auditory implants require prior authorization (codes such as 69710, 69714, 69930, L8614, L8619 referenced).

Example codesExamples listed in policy: 69710, 69714, 69930, L8614, L8619.

inv-70: DME

DefinitionDME (Durable Medical Equipment): items listed in the policy; some are exempt from prior authorization unless rental cost exceeds $500 or item is specifically noted.

ThresholdPrior authorization required when DME rental cost exceeds $500 (policy example E0265/E0266 references rental cost > $500).

Incontinence suppliesIncontinence supplies are a covered benefit when provided; ordering via Medline at 877-816-5587 (prior auth rules noted separately).

inv-71: Enteral/in-home nutritional therapy

DefinitionEnteral/in-home nutritional therapy: in-home enteral nutrition services identified by multiple B4xxx HCPCS codes (e.g., B4034-B4036, B4100-B4161).

Prior authorizationPrior authorization is required for enteral/in-home nutritional therapy (B4034, B4035, B4036, B4100, etc.).

Ordering noteCodes and services listed in the enteral section must follow prior authorization process per the policy listing.

inv-72: Genetic and Molecular Testing Prior Authorization/Notification Program

ProgramGenetic and Molecular Testing Prior Authorization/Notification Program: tests must be registered and providers must complete prior authorization/notification process for outpatient testing.

ScopeIncludes genetic and molecular testing such as BRCA and numerous CPT codes (e.g., 81162, 81229, 81401, 81405, 87505, 81519, 81523).

RequirementPayment authorized only for CPT codes registered with the Genetic and Molecular Testing Prior Authorization/Notification Program.

inv-73: Home health prior authorization scope

ScopeHome health prior authorization is required only in outpatient settings, including services provided in the patient's home.

Example codesHome health services include G0151, G0152, G0153, G0155 and other listed G-/S-/T- codes for home health.

ExceptionPrior authorization is not required for members residing in a skilled nursing facility (per this section).

inv-74: Prior Authorization and Notification tool (UHCprovider.com)

ToolPrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — use the Prior Authorization and Notification tab on your dashboard to submit requests.

Phone alternativeFor Home- and Community-Based Services injectable and other requests, call 888-397-8129 as indicated in that section.

Access noteSign in with One Healthcare ID; instructions available at UHCprovider.com/access if you need an ID.

inv-75: Emergency admission notification

RequirementFor emergency inpatient admissions, notify UnitedHealthcare within 48 hours of admission.

Routine obstetricsRoutine obstetrics/deliveries require notification only (not full prior authorization in routine cases).

Submission methodTo request inpatient prior authorization, fax the member's registration/admission document with pertinent information to UnitedHealthcare Community Plan of Hawaii at 800-267-8328.

inv-76: Private duty nursing (as used in this section)

Definition/ScopePrivate duty nursing (as used in this section): prior authorization is required (noted as 'Prior authorization only required').

Example codesPrivate duty nursing codes listed include T1002 and T1003.

ActionSubmit prior authorization per the policy process for these services when applicable.

inv-77: Potentially unproven services

DefinitionPotentially unproven services: services identified in the policy considered potentially unproven require prior authorization.

ExamplesExamples listed include CPT/HCPCS codes 33289 and C2624 (policy notes these as examples of potentially unproven services).

ActionProviders must obtain prior authorization before performing services listed as potentially unproven.

inv-78: Stimulators

DefinitionStimulators: implantation of a device that sends electrical impulses (policy references multiple E07xx neurostimulator/bone growth stimulator codes).

Prior authorizationPrior authorization required for listed stimulator device codes (examples include E0747, E0748, E0749, E0760).

Related device codesBone growth stimulator/neurostimulator codes (E0747, E0748) are specifically referenced in the stimulators section.

inv-79: Wound vac

DefinitionWound vacuum (wound vac): negative pressure wound therapy device referenced in policy.

Prior authorizationPrior authorization is required for wound vac device code E2402.

Policy placementWound vac and associated HCPCS code E2402 are listed in the Home- and Community-Based Services device/code listings requiring prior authorization.