CurrentUnitedHealthcarePolicy PCA-2-23-02622-POE-WEB_09212023

Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi (MississippiCAN)

Lists procedures, services, CPT/HCPCS/ICD-10 codes and submission methods that require prior authorization for participating UnitedHealthcare Community Plan of Mississippi (MississippiCAN) providers; applies to in-network and out-of-network providers and excludes emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Mississippi (MississippiCAN)

Policy CodePolicy PCA-2-23-02622-POE-WEB_09212023

Change TypeMinor / no material changes

Effective DateOct. 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, or by phone 877-842-3210, or fax 888-310-6858.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Oct. 1, 2024effective date shown on document header

3ways to submit prior authorization requests

877-842-3210phone number for prior auth (general)

888-310-6858fax number for prior auth (general)

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.

elective inpatient PA timeframe

24 hoursurgent/emergent admission notification

Services and Codes Requiring Prior Authorization

Prior authorization coverage criteria

The document lists service categories and specific CPT/HCPCS/ICD-10 codes that require prior authorization and any submission-specific instructions.

Behavioral health — Prior authorization required. For specific codes call the number on the member's health plan ID card; applied behavior analysis (ABA) therapy submissions via fax or Provider Express.

Bone growth stimulator — Prior authorization required. CPT codes: 20975, 20979.

ALL of the following

Codes: 11971, 19318, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, L8600.

ALL of the following

Example codes include Q5110, Q5125, Q5101, J1449, J2506, Q5122, Q5120, Q5111, Q5108, J2820 and others as listed in document.

ALL of the following

Reference CPT/HCPCS examples: 37220–37231, 93580 and related diagnosis codes as listed.

Prior authorization coverage examples

Selected services/items require prior authorization when billed with the listed codes.

ALL of the following

Codes/range: J9000–J9999; J0640, J0641, J0642; J1950; J1952; Q‑codes and miscellaneous HCPCS when applicable.

ALL of the following

Code: 54161.

ALL of the following

Codes: 69714, 69930 and device HCPCS L8614, L8619 (and related L8690–L8692 as listed).

ALL of the following

Prior authorization coverage criteria (partial)

Coverage stance: many services require prior authorization or notification as specified below.

Elective inpatient PA: Prior authorization required at least 5 business days prior to non-urgent elective/planned inpatient admissions.

Urgent/emergent admissions: Prior authorization not required for urgent or emergent inpatient admissions; notification of admissions required within 24 hours.

EPSDT non-covered codes: Prior authorization required for members younger than age 21 for non-covered codes (EPSDT).

Enteral/parenteral in-home nutrition: Prior authorization required for some enteral and parenteral in-home nutritional therapy products; example codes: B4034, B4035, B4036, B9002.

Experimental/investigational services

Prior authorization requirements (excerpt)

Services and codes in this excerpt require prior authorization as noted below.

Injectable medications — Prior authorization required for listed injectable medications (numerous J/Q codes); submit via Provider Portal or call the specified phone number.

ALL of the following

Example codes: 27120, 27486, 27487, 29866, 29867.

ALL of the following

Codes: A0430, A0431, A0435, A0436.

ALL of the following

Example L‑codes: L0112, L0170, L0456, L0462 (many others listed).

Authorization requirements for select services

Coverage/authorization stance for listed services and codes in these chunks:

Out‑of‑network services — All out‑of‑network services require prior authorization.

ALL of the following

Codes: T2002, T1025, T1026.

ALL of the following

Codes: S9122, S9123, S9124.

ALL of the following

Examples: IMRT codes 77385/77386 and proton codes 77520–77525; standard RT codes 77401/77402 etc., with diagnosis ranges C34.x, C50.x, C61, C79.51–C79.52, D05.x listed.

Prior authorization requirements

Procedures and CPT/HCPCS codes listed in the document require prior authorization or notification, particularly when performed in an outpatient hospital setting.

Site‑of‑service rule — Prior authorization is required only when requesting service in an outpatient hospital setting for many listed CPT/HCPCS codes; if performed at a participating ambulatory site prior authorization may not be required.

ALL of the following

Sample spinal codes: 22100, 22101, 22102, 22110 (and many additional spinal CPTs listed).

ALL of the following

Codes: 95805, 95807, 95808, 95810.

Prior authorization criteria excerpts

Procedures and services flagged in this portion require prior authorization or notification as noted.

ALL of the following

Codes: 95805, 95807, 95808, 95810.

ALL of the following

Representative codes: 63308, 61863, 61864, 61867, 61868 and implant HCPCS such as L8682 and related E0747–E0760 bone growth stimulator codes.

ALL of the following

Contact phone: 888-936-7246; example procedure codes include 0537T–0540T and various related HCPCS/J codes.

ALL of the following

CPT / HCPCS / ICD-10 Code Lists

Breast reconstruction (non-mastectomy) codesCPT | HCPCSCovered

11971	Breast reconstruction (non-mastectomy)
19318	Breast reconstruction (non-mastectomy)
19328	Breast reconstruction (non-mastectomy)
19330	Breast reconstruction (non-mastectomy)
19340	Breast reconstruction (non-mastectomy)
19342	Breast reconstruction (non-mastectomy)
19350	Breast reconstruction (non-mastectomy)
19357	Breast reconstruction (non-mastectomy)
19361	Breast reconstruction (non-mastectomy)
19364	Breast reconstruction (non-mastectomy)

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Cancer supportive care drug HCPCS/J-codesHCPCSCovered

Q5110	Filgrastim-aafi (Nivestym™)
Q5125	Filgrastim-ayow (Releuko®)
Q5101	Filgrastim-sndz (Zarxio®)
J1449	Eflapegrasstim-xnst (Rolvedon®)
J2506	Pegfilgrastim (Neulasta®)
Q5122	Pegfilgrastim-apgf (Nyvepria™)
Q5120	Pegfilgrastim-bmez (Ziextenzo®)
Q5111	Pegfilgrastim-cbqv (UDENYCA™)
Q5108	Pegfilgrastim-jmdb (Fulphila™)
J2820	Sargramostim (Leukine®)

1–10 of 17

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Cardiovascular / interventional codesCPT | ICD-10 | mixedCovered

37220	Endovascular code referenced
37221	Endovascular code referenced
37224	Endovascular code referenced
37225	Endovascular code referenced
37226	Endovascular code referenced
37227	Endovascular code referenced
37228	Endovascular code referenced
37229	Endovascular code referenced
37230	Endovascular code referenced
37231	Endovascular code referenced

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Selected CPT codes (cosmetic/reconstructive examples)CPT

11960	Cosmetic/reconstructive procedure code listed; prior authorization required
14020	Cosmetic/reconstructive procedure code listed (marked with *)
15821	Cosmetic/reconstructive procedure code listed
21137	Facial skeletal procedure code listed
21295	Reconstructive procedure code listed

Selected ICD-10 diagnosis codesICD-10

C43.51	Melanoma diagnosis code listed
C44.111	Nonmelanoma skin cancer diagnosis code listed
C44.1191	Nonmelanoma skin cancer diagnosis code listed

Sample DME/HCPCS codesHCPCSCovered

A6549	DME code listed that requires prior authorization
A9280	DME code listed that requires prior authorization
A9900	DME code listed that requires prior authorization
B4152	DME code listed that requires prior authorization
B4161	DME code listed that requires prior authorization
E0194	DME/HOT code listed that requires prior authorization

Procedure CPT codes requiring authorizationCPTCovered

31240-31256,31287	FESS procedure CPT codes
29914-29916	FAI procedure CPT codes

Sample injectable HCPCS codesHCPCSCovered

J0224	Oxlumo™
J1576	Panzyga®
J0606	Parsabiv™
J1745	Remicade®
Q5104	Renflexis®
J3399	Zymfentra

Air ambulance and orthotics/prosthetics codesHCPCSCovered

A0430	Non-emergent air ambulance
A0431	Non-emergent air ambulance
L0112	Orthotic/prosthetic code (example)

Joint replacement CPT codesCPTCovered

27120	Total hip arthroplasty
27486	Revision of total knee arthroplasty

Orthotics/Prosthetics L-code group (multiple L-codes listed across contiguous chunks)HCPCSCovered

L5990	Orthotics/prosthetics HCPCS L-code listed
L6010	Orthotics/prosthetics HCPCS L-code listed
L6050	Orthotics/prosthetics HCPCS L-code listed
L6100	Orthotics/prosthetics HCPCS L-code listed
L6600	Representative of many L-codes listed

Radiation therapy code groupmixedCovered

77401	Standard radiation therapy code mapping listed
77402	Standard radiation therapy code mapping listed
G6003	Radiation therapy HCPCS mapping listed
G6017	Radiation therapy advanced code

Selected procedural CPTs (prostate, radiation)CPTCovered

37243	Prostate procedures CPT referenced
53852	Prostate procedures CPT referenced
52441	Prostate procedures CPT referenced
52442	Prostate procedures CPT referenced

Sample listed CPT codes requiring prior authorizationCPTCovered

95805	Sleep study (prior auth required)
95807	Sleep study (prior auth required)
95808	Sleep study (prior auth required)
95810	Sleep study (prior auth required)
22100	Spinal surgery (prior auth required)
22101	Spinal surgery (prior auth required)
22102	Spinal surgery (prior auth required)
22110	Spinal surgery (prior auth required)

Additional examples from multiple specialtiesCPTCovered

43235	Upper gastrointestinal endoscopy
43239	Upper gastrointestinal endoscopy
43249	Upper gastrointestinal endoscopy
49505	Hernia repair
67010	Ophthalmic procedure

Sleep study codesCPTCovered

95805	Polysomnography
95807	Sleep study w/ CPAP titration

Stimulator and implant codesmixedCovered

63308	Craniotomy or related neurostimulator procedure (document lists as anchor code)
E0747	Bone growth stimulator
L8682	Implantable neurostimulator component

Wound VAC codesHCPCSCovered

E2402

Negative pressure wound therapy (wound VAC) supply

inv-26: Behavioral health referral — use the number on the member's health plan ID card to refer for mental health and substance use services.

Referral phone numberCall the number on the member's health plan ID card to refer for mental health and substance use services

Behavioral health prior authorizationBehavioral health services require prior authorization through Optum Behavioral Health network

ABA therapy submissionFor applied behavior analysis (ABA) therapy, submit requests via fax or Provider Express

How Providers Must Submit and Notify

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 (UHCprovider). Sign in at UHCprovider.com using your One Healthcare ID and password, then select the Prior Authorization and Notification tab. If you do not have a One Healthcare ID, visit UHCprovider.com/access. You may also call 877-842-3210 or fax 888-310-6858. Prior authorization is not required for emergency or urgent care. All out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Online: Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider) — UHCprovider.com > Sign In > Prior Authorization and Notification tab.
Phone: 877-842-3210
Fax: 888-310-6858
Prior authorization is not required for emergency or urgent care.
All out-of-network services require prior authorization; referrals to providers not contracted with UnitedHealthcare must have prior authorization.

Prior Authorization

ENT procedures — Prior authorization required

Key Terms and Process Definitions

inv-58: Prior authorization — definition entry for 'Prior authorization'.

DefinitionPrior authorization: A process by which UnitedHealthcare reviews and approves specified services before they are provided

When requiredRequired for services and codes listed in this policy; not required for emergency or urgent care

Submission methodsRequests may be submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, phone, or fax as specified in the policy

inv-59: ABA therapy — applied behavior analysis submissions are to be sent via fax or Provider Express.

ABA therapy submission methodApplied behavior analysis (ABA) therapy requests should be submitted via fax or Provider Express

Behavioral health network

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Mississippi (MississippiCAN)

Policy CodePolicy PCA-2-23-02622-POE-WEB_09212023

Change TypeMinor / no material changes

Effective DateOct. 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, or by phone 877-842-3210, or fax 888-310-6858.

SourceLink

On This Page

Example codes: A6549, A9280, A9900, B4152, B4161, E0194, E0265, E0266.

Example codes: 33477, 36514, 64722, 66180.

Injectable medications: An extensive list of injectable medications require prior authorization; ordering provider must follow notification/submission process as specified.

Rhinoplasty (functional impairment/septal deviation) and sinuplasty — Prior authorization required; providers must notify prior to scheduling advanced outpatient imaging procedures.

Fax: 855-282-8929; example codes listed for VAD procedures included in document.

ALL of the following

Example HCPCS code: E2402.

inv-27: Outpatient DME price threshold — more than $500 triggers rules (outpatient).

Outpatient DME price thresholdPrior authorization required for outpatient DME items priced more than $500

Example codes with outpatient thresholdE0300, E0328, E0329, E0445 (sample HCPCS appearing near threshold guidance)

Prosthetics noteProsthetics are noted separately and may not be classified as DME

inv-28: Cumulative rental cost threshold — prior authorization based on cumulative rental cost (value unspecified in this chunk).

Cumulative rental cost rulePrior authorization referenced when cumulative rental cost conditions apply (policy notes cumulative rental cost triggers)

Listed DME examplesA6549, A9280, A9900, B4152, B4161, E0194 (DME codes listed in same section)

Authorization scopePrior authorization required only for the DME codes explicitly listed in the policy excerpt

inv-29: Orthotics/prosthetics rental cumulative cost threshold — $500.

Orthotics/prosthetics rental cumulative cost thresholdPrior authorization required when cumulative rental cost exceeds $500

Only listed codes require prior authorizationPrior authorization required only for orthotics/prosthetics codes explicitly listed in the policy

Sample L-codes referencedL0112, L0170, L0456, L0462, L0632 (examples of orthotics/prosthetics L-codes in policy)

inv-30: Standard RT prior auth trigger — Standard RT requires prior authorization only when obtained with listed diagnosis codes (e.g., select C and D codes).

Standard RT prior authorization triggerStandard (2D/3D) radiation therapy requires prior authorization only when obtained with diagnosis codes in the specified ranges (e.g., C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, D05.00–D05.92)

Representative CPT/HCPCS77401, 77402, G6003, G6011 and related mappings are listed in the radiation therapy section

Submission pathwaySubmit prior authorization via the UnitedHealthcare Provider Portal Radiology/Cardiology/Oncology and Radiation Therapy selection (portal redirects) or call the phone alternative

Rhinoplasty for treatment of functional nasal impairment and septal deviation, and sinuplasty procedures require prior authorization. Health care professionals ordering these procedures or advanced outpatient imaging related to them are responsible for providing notification prior to scheduling. Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider) or call 866-889-8054. For details and lists of CPT codes that require prior authorization, visit the Radiology Prior Authorization and Notification Program or the program pages referenced for rhinoplasty/sinuplasty.

Rhinoplasty (functional impairment/septal deviation) — prior authorization required (see CPT ranges 30400–30462 for procedure-specific guidance).
Sinuplasty — prior authorization required (see CPT codes 31295–31298).
Notification required prior to scheduling advanced outpatient imaging related to these ENT procedures.
Submit online via UHCprovider or call 866-889-8054.

Behavioral health services are managed through the Optum Behavioral Health network; refer to Providerexpress.com for details

Referral contactFor specific behavioral health codes, call the number on the member's health plan ID card

inv-60: Chemotherapy injectable drugs — chemotherapy injectable drugs J9000-J9999 plus specified J- and Q-codes referenced.

Chemotherapy injectable drug rangeChemotherapy injectable drugs billed in an outpatient setting require prior authorization — HCPCS range J9000–J9999

Included specific codesLeucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), Leuprolide (J1952) listed as examples

Q-code and miscellaneous billingChemotherapy drugs with Q-codes or not-yet-assigned codes billed under miscellaneous HCPCS also require prior authorization

inv-61: DME — prior authorization required only for the DME codes explicitly listed.

DME prior authorization scopePrior authorization required only for the DME codes explicitly listed in the policy (examples include A6549, A9280, A9900, B4152, B4161, E0194)

Cumulative rental cost notePolicy references cumulative rental cost conditions related to authorization (see orthotics/prosthetics sections for thresholds)

Authorization applies to listed billed amountsAuthorization applies to listed codes with a billed amount or as specified in policy entries

inv-62: EPSDT — Expanded Early and Periodic Screening, Diagnostic and Treatment; prior authorization required for non-covered codes for members younger than age 21.

EPSDT prior authorization ruleEPSDT: Prior authorization is required for non-covered codes for members younger than age 21

Regulatory referenceSee Mississippi Medicaid Administrative Code Part 200 for EPSDT guidance (policy references state rules)

Submission noteFollow prior authorization submission methods in the policy when requesting EPSDT-related authorizations

inv-63: DME (alternate) — durable medical equipment; prior authorization required only for listed DME codes.

DME authorization (alternate entry)Durable medical equipment prior authorization applies only to the specific DME codes listed in the policy excerpt

Sample listed DME codesA6549, A9280, A9900, B4152, B4161, E0194, E0265, E0266

Cumulative rental cross-referenceCumulative rental cost references appear in adjacent orthotics/prosthetics sections

inv-64: UnitedHealthcare Provider Portal submission process — One Healthcare ID or phone 888-397-8129 referenced for portal access.

Portal access requirementUse One Healthcare ID to sign in at UHCprovider.com to access the Prior Authorization and Notification tool

Phone alternative for portal submissionsOr call 888-397-8129 for prior authorization assistance for injectable medications as noted in the policy

Portal navigation noteSelect the Prior Authorization and Notification tab on your dashboard after signing in

inv-65: Out-of-network services — definition/statement that out-of-network services require prior authorization.

Out-of-network services ruleAll out-of-network services require prior authorization

Examples requiring special submissionPrescribed pediatric extended care (T2002, T1025, T1026) and private duty nursing (S9122–S9124) require prior authorization and specific form guidance

Referral contextReferrals to non-contracted providers are subject to the out-of-network prior authorization requirement

inv-66: UHCprovider.com Prior Authorization and Notification tool — portal named as submission tool.

Portal tool namePrior Authorization and Notification tool on UHCprovider.com (select Radiology/Cardiology/Oncology and Radiation Therapy as appropriate)

Portal workflow noteAfter selecting Commercial product type the portal redirects to process authorization requests for certain service types

Alternate contactPhone alternatives are provided in the policy for specific program areas (see radiation oncology phone guidance)

inv-67: Prior authorization / Notification — definition describing the process by which providers notify UnitedHealthcare or obtain approval before scheduling advanced services.

Process definitionPrior authorization / Notification: The process by which providers notify UnitedHealthcare or obtain approval before scheduling advanced outpatient imaging or certain procedures

When notification requiredHealth care professionals ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling

How to submitSubmit requests via the Provider Portal Prior Authorization and Notification tool or call the phone numbers listed in the policy (e.g., 866-889-8054 for radiology)

inv-68: Transplants / CAR T-Cell therapy — definition entry for transplant and CAR T-cell therapy services referenced for specialized handling.

Transplants / CAR T-cell therapy requirementTransplants and CAR T-cell therapy services require prior authorization/notification

Transplant case management contactCall the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 for transplant/CAR T requests

CAR T examplesCAR T therapies listed in policy include tisagenlecleucel, brexucabtagene autoleucel, axicabtagene (policy references Yescarta, Tecartus, etc.)

inv-69: VAD — Ventricular assist device definition.

VAD definitionVentricular assist device (VAD): A mechanical pump that takes over the function of a damaged ventricle

Authorization / notification stepsPlease call the notification number on the back of the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929

Associated codes/contextVADs and related entries are listed in the surgical/advanced therapies section and are subject to site-of-service rules where applicable