UnitedHealthcare Prior Auth Requirements NJ Medicaid

Services Requiring Prior Authorization

inv-02: Extracted coverage criteria (partial) — Statements about prior authorization requirements for specific services and how to request authorization.

Statements about prior authorization requirements for specific services and how to request authorization.

ALL of the following

Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting, including intravenous, intravesical and intrathecal agents (codes J9000-J9999 and specified J-codes).
For prior authorization requests, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) as the primary submission method; portal instructions are provided in the document.
EEG rules
- Inpatient video electroencephalogram (EEG) prior authorization is not required.
- Outpatient EEG requires prior authorization for outpatient hospital or ambulatory surgical center settings (EEG CPT examples listed in the policy).
Cosmetic and reconstructive procedures are listed with CPT/HCPCS codes and generally require prior authorization unless billed with specified diagnosis codes that exempt PA (document lists ICD-10 diagnoses that exempt PA).

inv-03: Partial coverage/prior authorization notes — Partial list of codes and related prior authorization notes included in this excerpt.

Partial list of codes and related prior authorization notes included in this excerpt.

ANY of the following

Certain cosmetic and reconstructive procedures are exempt from prior authorization when billed with specified diagnosis codes (ICD-10 codes such as C43.0, C43.10, C43.111, etc., are listed as exemptions).
Durable medical equipment (DME): prior authorization is required only for listed DME codes with a retail purchase or cumulative rental cost greater than $500 (examples include A9279, A9280, A9900).
Enteral and in-home nutritional services: prior authorization is required in specified circumstances; for members younger than age 5, prior authorization is required for certain in-home nutritional therapy/enteral codes (examples: B4034, B4035, B4036, B4100, B4152).

inv-04: Prior authorization requirements (partial) — Coverage stance and criteria (partial):

Coverage stance and criteria (partial):

ALL of the following

Advanced outpatient imaging procedures (certain CT, MRI, MRA, PET and nuclear medicine/nuclear cardiology procedures) require prior authorization and providers must provide notification prior to scheduling.
Outpatient therapy services listed (outpatient therapy CPT codes) require prior authorization.
Site-of-service rule: prior authorization is required when requesting service in an outpatient hospital setting; prior authorization is not required if the same procedure is performed at a participating Ambulatory Surgery Center (ASC).

inv-05: Authorization listing — Prior authorization codes and medication list

Prior authorization codes and medication list

ALL of the following

The policy lists numerous injectable medications and corresponding HCPCS/J-codes that require prior authorization; repeated examples include IVIG-related codes and specialty drugs (e.g., J0879 Krystexxa; J2507).
White blood cell colony-stimulating factors and related J/Q codes are enumerated (examples include J1442, J1447, J2506, Q5101, Q5110, Q5122, Q5125); some codes have prior-authorization rules for oncology vs non-oncology use noted in the policy.
For prior authorization of listed medications, submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the telephone numbers provided in the document (e.g., 888-397-8129 referenced for medication PA).

inv-06: Prior authorization criteria (partial) — Prior authorization requirements and special notes found in this fragment.

Prior authorization requirements and special notes found in this fragment:

ALL of the following

Prior authorization is required for joint replacement procedures (total hip and knee) listed by CPT codes (examples include 23470, 23472, 27120 series, 27486, 27487 and related CPTs).
Prior authorization is required for orthognathic surgery codes listed (examples include CPT 21121, 21123, 21125, 21127, 21141, 21142, etc.).
Non-emergent air ambulance transport requires prior authorization (examples: A0430, A0431, A0436, S9960, S9961 listed).
Orthotics and prosthetics: prior authorization is required only for items with retail purchase or cumulative rental cost greater than $500 (HCPCS L-code examples provided).

inv-07: Prior authorization requirements (partial) — Authorization and site-of-service criteria (partial).

Authorization and site-of-service criteria (partial):

ALL of the following

Orthotics and prosthetics (HCPCS L-codes) are listed with prior authorization instructions; some L-code entries indicate prior authorization is required for the listed items.
Outpatient therapy CPT codes are listed and outpatient therapy is noted as requiring prior authorization (examples include CPTs 92507, 97010, 97110, 97530 and other therapy codes).
Site-of-service rule: prior authorization is required for services requested in an outpatient hospital; participating Ambulatory Surgery Centers (ASCs) are exempt from prior authorization for listed services.

inv-08: Prior authorization stance (partial) — Prior authorization criteria by service and site (partial).

Prior authorization criteria by service and site (partial).

ANY of the following

Prior authorization is required when services are requested in an outpatient hospital setting (site-of-service requirement).
Prior authorization is not required if the procedure is performed at a participating Ambulatory Surgery Center (ASC).
Certain procedures require prior authorization regardless of site, including spinal surgery CPT ranges and sleep studies/sleep apnea procedures (sleep study CPTs 95805-95811 require PA and site-of-service review).

inv-09: Prior authorization requirements — Prior authorization and contact instructions for selected services

Prior authorization and contact instructions for selected services

ALL of the following

Stimulators and neurostimulators require prior authorization (examples include codes 0098T, E0760, L8680, L8682, L8685-L8688 and device CPTs such as 61863, 61864, 63650, 63655, 64553, 64555).
Transplant and CAR T-cell therapy services require prior authorization via UnitedHealthcare Community and State Transplant Case Management or Optum Transplant for certain codes; specific CAR T products are named and providers should contact the transplant case management team (contact numbers and process noted in the document).
Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the back of the member's health plan ID card and fax the provided form to the Optum VAD Case Management Team at 855-282-8929.
Wound VAC therapy (HCPCS E2402) requires prior authorization.

Code Lists and Status

Cancer supportive care J/Q codesHCPCS | mixedCovered

J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen) *requires prior auth for oncology and some non-oncology
Q5110	Filgrastim-aafi (Nivestym)
Q5101	Filgrastim-sndz (Zarxio)
Q5125	Filgrastim-ayow (Releuko)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5108	Pegfilgrastim-jmdb (Fulphila)

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Breast reconstruction codesCPT | HCPCSCovered

11971	Breast reconstruction (non-mastectomy)
19316	Breast reconstruction (non-mastectomy)
19318	Breast reconstruction (non-mastectomy)
19325	Breconstruction/reconstruction related CPTs
L8600	Breast prosthesis

Cardiovascular CPT/diagnosis codesCPT | ICD-10 | mixedCovered

37220	Endovascular intervention codes (examples listed with prior auth)
37226	Endovascular intervention codes
37221	Endovascular intervention codes
37227	Endovascular intervention codes
93580	Cardiac catheterization code

Cardiovascular ICD-10 codes (partial list)ICD-10

I70.532	ICD-10 code listed in cardiovascular section
I70.533	ICD-10 code listed in cardiovascular section
I70.534	ICD-10 code listed in cardiovascular section

Selected CPT/HCPCS/J-code examplesmixed

95700	Cerebral seizure monitoring
95711	Cerebral seizure monitoring
95714	Inpatient video EEG
L8619	Cochlear implant HCPCS code
69710	Cochlear implant CPT code
J9000-J9999	Range for chemotherapy injectable drugs

Ophthalmic / reconstructive CPT/HCPCS codes (partial)CPT | HCPCS

67903
67904
67906
67908
67909
67911
67912
67914
67915
67916

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Diagnosis ICD-10 codes exempting prior authorization for cosmetic/reconstructive (partial)ICD-10

C43.0	Malignant melanoma of lip
C43.10
C43.111
C44.01
C44.1021

Durable medical equipment codes (partial)HCPCS

E0194
E0265
E0266
E0270

Enteral / gastrostomy HCPCS codes (partial)HCPCS

B4159	Gastrostomy tube
B4160	Gastrostomy tube
B4161	Gastrostomy tube
B9002

Enteral and in-home nutritional HCPCS codesHCPCSCovered

B4034	Enteral services - in-home nutritional
B4035	Enteral services - in-home nutritional
B4036	Enteral services - in-home nutritional
B4100	In-home nutritional therapy
B4102	In-home nutritional therapy

Genetic/molecular testing (BRCA) CPT codesCPTCovered

81162	Genetic and molecular testing (example BRCA-associated code listed)
81163	Genetic and molecular testing
81403	BRCA testing (example code listed)
81404	BRCA testing

Selected hysterectomy and injectable medication codesmixedCovered

58150	Hysterectomy CPT code listed as prior authorization required
58152	Hysterectomy
J3262	Actemra® HCPCS/J-code (injectable) listed
J0801	Acthar®

Example HCPCS drug codes appearing in this sectionHCPCS

J1439	IVIG (listed repeatedly)
J0879	Korsuva
J2507	Krystexxa
J1290	Kalbitor
J2840	Kanuma
J3245	Ilumya

Selected injectable medication codesHCPCS

J0217	Lamzede
J1932	Lanreotide
J0202	Lemtrada
J0174	Leqembi
J1306	Leqvio
J2778	Lucentis

IVIG-related codesmixed

J1439	IVIG
90284	IV infusion code (listed with IVIG)

Injectable medications and related HCPCS/CPT codesHCPCS | CPTCovered

J9226	Supprelin LA
J2779	Susvimo
J2781	Syfovre
90378	Synagis
J3241	Tepezza
J2356	Tezspire
J3315	Trelstar
J3316	Triptodur
Q5115	Truxima
J2323	Tysabri

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Surgical, ambulance, orthognathic, and extensive orthotics/prosthetics HCPCS/CPT codesCPT | HCPCSCovered

23470	Joint replacement related CPT
23472	Joint replacement related CPT
23473	Joint replacement related CPT
23474	Joint replacement related CPT
24360	Joint replacement related CPT
24361	Joint replacement related CPT
24362	Joint replacement related CPT
24363	Joint replacement related CPT
27120	Joint replacement related CPT
27125	Joint replacement related CPT

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Sample L-code group (partial list shown)HCPCS

L5648	HCPCS L-code listed under white blood cell colony stimulating factors / orthotics & prosthetics section
L5649	HCPCS L-code listed

Radiology prior auth codes (partial)mixed

S2095	Advanced outpatient imaging - listed CPT/HCPCS code requiring prior authorization
77371	Radiation therapy/planning code requiring prior authorization

Procedure CPT examples (partial)CPT

36590	Cardiovascular system - code listed
64721	Carpal tunnel surgery
66982	Cataract surgery (listed among codes)

Sample CPTs from partial listmixed

69205	Ear procedure code listed
36590	Cardiovascular procedure code listed
36832	Cardiovascular procedure code listed
64721	Carpal tunnel surgery
66821	Cataract surgery
45378	Colonoscopy

Sleep study CPT codesCPTCovered

95805	Sleep study, in-lab polysomnography
95807	Split-night polysomnography
95808	Multiple sleep latency test
95810	Polysomnography with initiation of CPAP
95811	Polysomnography with initiation of bi-level pressure support

Examples of surgical/spinal procedure codes requiring prior authorizationCPTCovered

22556	Spinal surgery — prior auth listed
22630	Spinal fusion — prior auth listed
22802	Spinal instrumentation — prior auth listed
63001	Laminectomy/laminotomy — prior auth listed

Transplant / gene therapy related HCPCS/J-codesHCPCSCovered

C9399	Miscellaneous chemotherapy/biologic — CAR T/gene therapies noted
J3490	Unclassified drugs — CAR T/gene therapies noted
J3590	Unclassified biologics — CAR T/gene therapies noted

Non-oncology prior authorization for selected J/Q codes

Affected codesJ1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125

ScopeThese codes require prior authorization when used for non-oncology (non-cancer) diagnoses

Reference sectionSee Injectable medications / White blood cell colony stimulating factors list for details

Chemotherapy prior auth scope

ScopeInjectable chemotherapy drugs administered in an outpatient setting require prior authorization (includes intravenous, intravesical, intrathecal)

Code range examplesChemotherapy injectable drugs J9000–J9999 and specified J-codes (Leucovorin J0640, Levoleucovorin J0641/J6042, Lupron Depot J1950, Leuprolide J1952)

How to submitSubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone per portal instructions

DME prior authorization cost threshold

ThresholdPrior authorization required only for DME items with retail purchase or cumulative rental cost greater than $500

Example DME codesA9279, A9280, A9900, E0194, E0265, E0266, E0270 (listed among DME entries)

NoteProsthetics are not considered DME — see orthotics and prosthetics section for separate rules

Orthotics/prosthetics prior authorization threshold

ThresholdPrior authorization required only for orthotics and prosthetic items with retail purchase or cumulative rental cost greater than $500

Example L-codesL0112, L0170, L0456, L0462, L0464 (sample prosthetic/orthotic codes listed)

SubmissionSubmit prior authorization via the Provider Portal Prior Authorization and Notification tool

How Providers Should Request Authorization

Prior Authorization

How to request prior authorization

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → UnitedHealthcare Provider Portal → Prior Authorization and Notification tool) or by phone at 877-842-3210. Prior authorization is not required for emergency or urgent care; out-of-network providers must submit prior authorization for all non-emergent procedures and services.

Online: Use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com).
Phone: 877-842-3210.
Do not use the Universal Referral Form (URF) in place of the prior authorization request form.

Prior Authorization

Cardiology prior authorization contact

For certain cardiology outpatient and office-based procedures (including diagnostic catheterizations, electrophysiology implants, and stress echoes), submit requests via the Provider Portal Prior Authorization and Notification tool or call the cardiology prior authorization numbers as listed (866-889-8054 or 888-397-8129).

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal.
Phone contacts: 866-889-8054 or 888-397-8129 (as noted).

Prior Authorization

Submission method for prior authorization

All prior authorization requests should be submitted online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → Provider Portal → Prior Authorization and Notification tool).

Go to UHCprovider.com and click the UnitedHealthcare Provider Portal button in the top right.
Select the Prior Authorization and Notification tool on the Provider Portal dashboard.

Prior Authorization

Services requiring prior authorization (examples)

Prior authorization is required for many services; examples include outpatient/ambulatory injectable chemotherapy drugs (J9000–J9999 and specified J‑codes) and cochlear implants/other auditory implants.

Injectable chemotherapy drugs administered in an outpatient setting (IV, intravesical, intrathecal) require prior authorization (J9000–J9999 and specified J‑codes).
Cochlear implants and other auditory implants require prior authorization (e.g., CPT 69710, HCPCS L8619).

Prior Authorization

EEG prior authorization notes

Inpatient video EEG does not require prior authorization; EEG services performed in outpatient hospital or ambulatory surgical center settings require prior authorization.

Inpatient video EEG (CPT 95714–95718): prior authorization not required.
Outpatient EEG (CPT 95720, 95722, 95724, 95726, etc.): prior authorization required for outpatient hospital or ASC.

Billing Rule

DME prior authorization threshold

Prior authorization is required only for DME items listed whose retail purchase or cumulative rental cost exceeds $500.

DME codes (e.g., A9279, A9280, A9900) require prior authorization only when retail purchase or cumulative rental cost is > $500.

Prior Authorization

Enteral / In-home nutritional prior authorization

Enteral and in‑home nutritional services require prior authorization in specified circumstances; some in‑home nutritional therapy codes require prior authorization for members younger than age 5.

Enteral/in‑home nutritional codes include B4034, B4035, B4036, B4100, B4102, B4152, etc.
Prior authorization required for members younger than age 5 for certain in‑home nutritional therapy codes.

Documentation Required

WIC denials and BRCA genetic testing notification

When a Written Institutional Coverage (WIC) denial applies (for example, genetic testing/BRCA or certain experimental/investigational items), submit the WIC denial along with your prior authorization request; BRCA testing requires notification/prior authorization before DNA sequencing and the ordering provider must notify the laboratory.

Submit the WIC denial with the prior authorization request for BRCA and other specified services.
Notification/prior authorization required for BRCA testing before DNA sequencing; the ordering provider must notify the lab and the lab will notify UnitedHealthcare.

Prior Authorization

Authorization requirements for HCBS/MLTSS, home health, hospice

Prior authorization is required for all Home and Community Based Services (HCBS) and Long‑Term Services and Supports (LTSS) for members in the MLTSS program; home health requires prior authorization when provided in outpatient settings (including the member’s home) and inpatient hospice admissions require prior authorization.

All HCBS and LTSS services for MLTSS members require authorization.
Home health: prior authorization required only in outpatient settings, including member’s home (e.g., G0494, G0495, G0496).
Hospice: prior authorization required for inpatient admissions (e.g., T2044).

Prior Authorization

Injectable medications prior authorization

A long list of injectable medications shown in the document require prior authorization; the policy lists many HCPCS/J‑codes that must be authorized before administration.

Examples include Actemra (J3262), Prolia (J0897 — requires PA for non‑oncology), IVIG/J1439, Krystexxa (J0879), Krystexxa/J2507, and many others listed.
For listed injectable medications, submit requests via the Prior Authorization and Notification tool or call 888-397-8129 as noted.

Prior Authorization

Enteral/in-home nutritional therapy authorization

Prior authorization is required for enteral/in‑home nutritional therapy for members younger than age 5 for specified codes; members ages 5 and older are noted separately.

Codes referenced include B4152, B4153, B4155, B4158, B4159, B4160, B4161 and others for enteral/gastrostomy supplies and in‑home nutritional therapy.
Prior authorization required for members younger than age 5 for some of these codes.

Prior Authorization

CPT/HCPCS codes requiring prior authorization (partial list)

The document lists numerous CPT/HCPCS/J codes that require prior authorization (partial list provided); providers should refer to the code lists in the policy for specific items and authorization context.

Partial examples include J0223, J9210, J0257, J1411, J1439, J0879, J2507 and many others.
Refer to the policy’s CPT/HCPCS code tables for the full list and authorization instructions.

Prior Authorization

Prior authorization codes mentioned

Specific medication codes mentioned in the policy include J0879 (Krystexxa) and J2507; these are listed as requiring prior authorization.

J0879 — Krystexxa®
J2507 — listed alongside J0879 in the policy.

Prior Authorization

IVIG and related codes

Multiple IVIG‑related codes (including J1439 and related infusion supply codes such as 90284) are listed and require prior authorization.

J1439 — IVIG (repeated entries).
90284 and related J‑codes are listed with IVIG entries.

Prior Authorization

Injectable medication codes

An extensive list of injectable medication HCPCS/J‑codes is included in the policy; providers must obtain prior authorization for the medications listed before administration.

Examples include J0217, J1932, J0202, J0174, J1306, J2778 and many others across the injectable medication listings.
Unclassified/temporary codes (C9162, C9167, C9168, J3490, J3590) require prior authorization only for specific listed drugs.

Prior Authorization

How to obtain prior authorization

For prior authorization, submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129 (as stated in the injectable medications section).

Online: Prior Authorization and Notification tool on UHCprovider.com.
Phone option provided: 888-397-8129 (per section guidance).

Prior Authorization

Radiology prior authorization

Advanced outpatient imaging procedures listed (see code list) require prior authorization; providers ordering these procedures must provide notification prior to scheduling and submit requests via the Provider Portal or by calling 866-889-8054.

Examples of codes: S2095, 77371, 77386, 77402, 79445, G6002, 77014, etc.
Submit PA requests via the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054.

Documentation Required

HCPCS L-code listings and prior authorization notes

Numerous HCPCS L‑codes for orthotics and prosthetics are listed with prior authorization notation; some entries include additional prior authorization instructions and provider submission notes.

Sample L‑codes shown: L5648, L5649, L7191, L7405, L8040–L8047, L8610, etc.
Outpatient therapy and orthotics/prosthetics entries are noted as requiring prior authorization.

Prior Authorization

Outpatient therapy prior authorization and CPT codes

Outpatient therapy services listed in the policy require prior authorization; the document provides CPT codes for these services which must be authorized prior to care.

Examples of outpatient therapy CPT codes requiring prior authorization include 92507, 92508, 97010, 97110, 97112, 97113, 97116, and many others.
Providers should obtain prior authorization before scheduling outpatient therapy services.

Billing Rule

Site of service prior authorization rule

If a service is requested to be performed in an outpatient hospital setting, prior authorization is required; the requirement does not apply when the service is performed at a participating Ambulatory Surgery Center (ASC).

Site‑of‑service rule: PA required for outpatient hospital; no PA required if performed at a participating ASC.

Prior Authorization

Site of service prior authorization rule

Prior authorization is required when requesting the listed services in an outpatient hospital setting; participating ASCs are exempt from prior authorization for those services.

Prior authorization only when requesting service in outpatient hospital setting.
Participating Ambulatory Surgery Centers (ASC) — prior authorization not required for the listed services.

Prior Authorization

Sleep studies and sleep apnea procedures

Sleep studies require prior authorization and a site‑of‑service review; certain sleep apnea procedures and surgeries also require prior authorization.

Sleep study CPTs listed: 95805, 95807, 95808, 95810, 95811 — prior authorization required.
Site‑of‑service review is also required for sleep studies; some sleep apnea surgeries require PA (e.g., maxillomandibular advancement).

Prior Authorization

Spinal surgery prior authorization

Numerous spinal surgery CPT codes listed in the policy require prior authorization; providers must obtain authorization before scheduling these procedures.

Examples of spinal surgery CPT codes requiring PA include 22100–22114 series, 22556, 22630, 22800–22861 ranges, and 63001–63055 series.
Prior authorization required for the spinal surgery procedures listed.

Prior Authorization

Stimulators / Neurostimulators prior auth

Various stimulators and implantable neurostimulator device codes (including 0098T, E0760, L8680–L8688 and CPT device codes 61863–63685, 64553–64590) require prior authorization.

Device examples: 0098T, E0760, L8680, L8682, L8685–L8688, CPT 61863, 61864, 61867, 61868, 61885, 61886, 63650, 63655, 63685, 64553, 64555, 64568, 64570, 64590.
Providers must obtain prior authorization for stimulators and neurostimulator implants.

Prior Authorization

Transplants and CAR T-cell therapy prior auth

Transplant and CAR T‑cell therapy services require prior authorization through the UnitedHealthcare Community and State Transplant Case Management Team (call 888-936-7246) or Optum Transplant for certain codes; specific CAR T products are named in the policy.

For CAR T products (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or follow the notification number on the member's ID card.
Prior authorization/notification is required for transplant and CAR T‑cell therapy services.

Prior Authorization

Ventricular assist device (VAD) prior auth

Ventricular assist devices (VADs) require prior authorization; providers should 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.

PA required for VADs (example CPT/HCPCS: 33927, 33928, 33929, 33975, 33976, 33979, 33981–33983, Q0507–Q0509).
Call the notification number on the member ID card and fax documentation to Optum VAD Case Management at 855-282-8929.

Prior Authorization

Wound vac prior auth

Wound vacs (HCPCS E2402) require prior authorization before use.

E2402 (wound vac) is specifically listed as requiring prior authorization.

Definitions and Operational Terms

Definition of Prior Authorization

DefinitionPrior authorization is the process by which participating providers must obtain approval (online via Provider Portal or by phone) before performing certain non-emergent services.

ExemptionPrior authorization is not required for emergency or urgent care

How to requestOnline via Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or by phone at 877-842-3210

URF — Universal Referral Form

DefinitionUniversal Referral Form (URF) is distinct from the prior authorization request form and must not be used in its place

ActionUse the prior authorization form or Provider Portal tool to submit requests

ReferenceSee Provider Portal instructions at UHCprovider.com (Provider Portal button → Prior Authorization and Notification tool)

Cochlear implants and other auditory implants

DefinitionCochlear implants and other auditory implants: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness

CodesExamples listed: CPT 69710, 69714, 69930 and HCPCS L8619, L8690, L8691, L8614, L8692

AuthorizationPrior authorization required for cochlear and other auditory implants

Exemptions to prior authorization for cosmetic and reconstructive services

Exemption conditionPrior authorization not required when cosmetic/reconstructive procedures are billed with specified diagnosis codes (ICD-10 list shown)

ExamplesICD-10 examples shown include C43.0, C43.10, C43.111, C43.112, etc.

Applicable sectionSee Cosmetic and reconstructive entries for full exempting diagnosis list

Prosthetics vs DME

ClarificationProsthetics are not classified as Durable Medical Equipment (DME); orthotics and prosthetics are managed under a separate section

ImplicationDifferent prior authorization thresholds apply to prosthetics versus DME (see respective sections)

ReferenceOrthotics and prosthetics listing with L‑codes and related prior authorization notes

MLTSS — Managed Long-Term Services and Supports

DefinitionManaged Long-Term Services and Supports (MLTSS): program for members receiving Home and Community Based Services (HCBS) and Long-Term Care Services (LTSS) where prior authorization is required

Authorization ruleAll HCBS and LTSS services for members on MLTSS require authorization

Home healthPrior authorization required for home health in outpatient settings (including member's home)

WIC denial — Written Institutional Coverage denial

DefinitionWIC denial — Written Institutional Coverage denial to be submitted with certain prior authorization requests as instructed

When requiredSubmit the WIC denial with prior authorization requests for services such as genetic/BRCA testing and certain endoscopic sinus procedures

PurposeUsed to support prior authorization for services that require payer review prior to performance

IVIG — Intravenous immunoglobulin (J1439)

DefinitionIVIG (intravenous immunoglobulin) — referenced in the policy with HCPCS code J1439 and associated infusion code 90284

CodesIVIG entries include J1439 and related infusion/supply codes (e.g., 90283, 90284) listed among injectable medications

Authorization noteIVIG and related codes are included in the list of injectable medications requiring prior authorization

Injectable medications

DefinitionInjectable medications: drugs administered via injection/infusion listed with HCPCS/J-codes that require prior authorization per the document

ExamplesExtensive list includes many medications such as J0217, J1932, J0202, J0174, J1306, J2778 and numerous others

Unclassified codesUnclassified/temporary codes (C9162, C9167, C9168, J3490, J3590) require prior authorization only for specified drugs listed

UnitedHealthcare Provider Portal prior authorization tool

Tool namePrior Authorization and Notification tool on UnitedHealthcare Provider Portal

AccessGo to UHCprovider.com and select the UnitedHealthcare Provider Portal button, then choose the Prior Authorization and Notification tool

AlternativePhone contact for portal-based submissions shown in sections (e.g., 888-397-8129 for certain requests)

Unclassified/temporary HCPCS/CPT codes

Codes notedUnclassified/temporary HCPCS/CPT codes C9162, C9167, C9168, J3490, J3590 require prior authorization only when used for specific listed drugs

Examples of specified drugsPolicy notes list select products (e.g., Adzynma, Eylea HD, Leqembi, Nulibry, Omvoh IV, Purified Cortrophin Gel, Recovi) for which these codes require prior authorization

ActionCheck Injectable medications section for which unclassified codes map to specific drugs before submitting PA

Prior Authorization and Notification tool on UnitedHealthcare Provider Portal

Tool referencePrior Authorization and Notification tool on UnitedHealthcare Provider Portal used for submitting PA requests

Portal instructionsGo to UHCprovider.com → UnitedHealthcare Provider Portal button → select Prior Authorization and Notification tool on dashboard

Phone alternativeRadiology prior auth phone number example: 866-889-8054 (portal accept phone submissions as indicated)

Site of service (SOS) rule

DefinitionSite of service (SOS) rule: prior authorization required when requesting service in an outpatient hospital setting; not required if performed at a participating Ambulatory Surgery Center (ASC)

ImplicationProviders must check site — procedures at participating ASCs are exempt from outpatient hospital PA requirement

ReferenceSee Site of service (SOS) outpatient hospital entry for full guidance

Outpatient hospital — definition (contextual)

DefinitionOutpatient hospital: setting where prior authorization is required for services listed when performed in this location

Relation to SOS rulePA required for outpatient hospital; if same service occurs at participating ASC, PA may not be required

ActionVerify scheduled site to determine PA requirement

Ambulatory Surgery Center (ASC)

DefinitionAmbulatory Surgery Center (ASC): participating ASCs are exempt from prior authorization for listed services that would otherwise require PA in an outpatient hospital setting

ActionIf service is scheduled at a participating ASC, PA is not required under SOS rule

VerificationConfirm ASC participation status before submitting PA

Ventricular assist devices (VAD)

DefinitionVentricular assist devices (VAD): a mechanical pump that takes over the function of the ventricle of the heart; prior authorization is required

ContactCall the notification number on the back of the member's health plan ID card and fax required forms to Optum VAD Case Management Team at 855-282-8929

ActionObtain prior authorization and follow Optum VAD case management instructions before scheduling

Stimulator / Neurostimulator

DefinitionStimulators/Neurostimulators: implantable devices that send electrical impulses (examples include bone growth stimulators and neurostimulators); prior authorization required

Example codes0098T, E0760, L8680, L8682, L8685, L8686, L8687, L8688, 61863, 61864, 61867, 61868, 61885, 61886, 63650, 63655, 63685, 64553, 64555, 64568, 64570, 64590 listed

ActionSubmit PA via Provider Portal or case management as directed in device section

Transplant / CAR T-cell therapy

DefinitionTransplant and CAR T-cell therapy services: include listed CAR T products (Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) and require prior authorization/notification

How to obtainCall UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card; Optum Transplant used for specified codes

Codes/ExamplesCAR T products and related HCPCS/J-codes (C9399, J3490, J3590, 38232, 0538T–0540T, Q2041–Q2056) referenced

OpenPayer

Prior authorization requirements for New Jersey Medicaid

Services Requiring Prior Authorization

Code Lists and Status

How Providers Should Request Authorization

Definitions and Operational Terms