How to submit prior authorization requests

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) by signing in with your One Healthcare ID and selecting the Prior Authorization and Notification tab, or connect via 24/7 chat. Prior authorization is not required for emergency or urgent care.

• Online: UHCprovider.com > Sign In > Prior Authorization and Notification tab (One Healthcare ID)
• Chat: Contact us page — available 24/7
• Emergency/urgent care is exempt from prior authorization

Arthroscopy prior authorization and site-of-service review

Prior authorization is required for the listed arthroscopy CPT codes; site-of-service will be reviewed as part of the prior authorization process except in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin.

• Examples of arthroscopy CPT codes shown (29805–29916 range referenced)
• Site-of-service review performed as part of PA except in listed states/territories

Cancer supportive care and anti-emetics prior authorization

Prior authorization is required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis; specified anti-emetics (Akynzeo, Cinvanti, Emend, Sustol) also require prior authorization.

• Colony-stimulating factor and bone-modifying agent codes listed require PA for outpatient cancer care
• Anti-emetic J-codes listed (e.g., J1454, J0185, J1453, J1456, J1627) require PA

Prior authorization requirement and submission instructions

Prior authorization is required for the listed colony-stimulating factor drugs, bone-modifying agents, erythropoiesis-stimulating agents and specified anti-emetics when administered in an outpatient setting for a cancer diagnosis; submit PA requests online via the UnitedHealthcare Provider Portal or by calling the numbers provided in the policy.

• Submit online: UHCprovider.com > Sign In > Prior Authorization and Notification
• Phone options referenced: 888-397-8129 and 866-889-8054 for prior authorization assistance

Prior authorization for injectable chemotherapy

Use the Prior Authorization and Notification tool on UnitedHealthcare to request prior authorization for injectable chemotherapy (chemotherapy injectable drugs billed J9000–J9999 and listed J-codes) and miscellaneous/unassigned chemotherapy HCPCS codes.

• Injectable chemotherapy drugs (J9000–J9999) require prior authorization for outpatient administration for a cancer diagnosis
• Also includes leucovorin (J0640), levoleucovorin (J0641, J0642) and other listed J-codes

CGM prior authorization (type 2 diabetes)

Continuous Glucose Monitor (CGM) devices require prior authorization when billed with a type 2 diabetes diagnosis; the policy lists the relevant HCPCS codes for CGM components and supplies.

• CGM HCPCS examples listed: A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103
• PA required when billed with type 2 diabetes diagnosis

Clinical trials prior authorization

Clinical trials and related services identified in the policy (e.g., S9988, S9990, S9991) require prior authorization.

• Clinical trials codes S9988, S9990, S9991 are listed as requiring prior authorization
• Advance/PA submission via the Prior Authorization and Notification tool

Cosmetic/reconstructive prior authorization (all states)

Cosmetic and reconstructive procedures require prior authorization in all states; the policy enumerates CPT codes subject to PA and notes some diagnosis-based exceptions.

• PA is required for cosmetic/reconstructive CPTs listed (examples include 11960, 14020, 14302, 15570)
• Some CPTs may be exempt from PA when billed with specified diagnosis codes (policy lists exceptions)

Advance notification for congenital heart disease services

For congenital heart disease–related services (including pretreatment evaluation), providers must give advance notification by calling 888-936-7246 or the notification number on the member's ID card and follow the instructions provided.

• Advance notification phone: 888-936-7246
• Notification number may also be on the back of the member's health plan ID card

Continuous Glucose Monitor HCPCS codes and PA requirement

Continuous Glucose Monitor prior authorization applies to the HCPCS codes listed in the policy (A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103) when billed with a type 2 diabetes diagnosis.

• Listed CGM HCPCS codes: A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103
• PA required when billed with type 2 diabetes diagnosis

Cosmetic and reconstructive procedures prior authorization (CPT codes listed)

Cosmetic and reconstructive CPT codes enumerated in the policy require prior authorization in all states; the document lists many specific CPT codes that fall under this requirement.

• Examples of listed CPTs: 11960, 11970, 14020, 14302, 15570, 15730, 15820
• Policy notes some codes may be exempt when billed with certain diagnosis codes

DME notification/prior authorization (cost threshold applies)

Durable medical equipment (DME) codes listed in the policy require notification or prior authorization only when the retail purchase or cumulative rental cost exceeds the cited threshold (over $1,000); some items (e.g., certain compressors) require authorization regardless of cost.

• DME purchase/cumulative rental cost threshold referenced: more than $1,000
• Certain items (e.g., specified compressors/accessories) may require authorization regardless of cost

ESRD dialysis notification / prior authorization

End-stage renal disease (ESRD) dialysis services require advance notification when members are referred to an out-of-network provider; call 877-842-3210 for notification/prior authorization.

• Advance notification phone for ESRD referrals to out-of-network providers: 877-842-3210
• Policy notes PA not required for ESRD diagnosis in some circumstances (see full policy)

Foot surgery prior authorization and site-of-service review

Prior authorization is required for the listed foot surgery CPT codes for all states; site-of-service will be reviewed as part of the prior authorization process except in specified states/territories.

• Foot surgery CPT examples listed (e.g., 28285–28299 range)
• Site-of-service review applies except in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin

Gastroenterology endoscopy prior authorization / notification guidance

Gastroenterology endoscopy (EGD, colonoscopy) and capsule endoscopy codes are referenced; advance notification is encouraged for participating providers and prior authorization submissions should be via the Provider Portal or by calling the provided number.

• Advance notification encouraged for participating providers
• Submit PA online at UHCprovider.com or call 866-889-8054
• Screening colonoscopy codes G0105 and G0121 are listed (SOS may apply)

Submission instructions and key screening colonoscopy codes

Please submit prior authorization requests online using the Prior Authorization and Notification tool on the Provider Portal (UHCprovider.com) or call 866-889-8054; key screening colonoscopy codes listed include G0105 and G0121.

• Online submission: UHCprovider.com > Sign In > Prior Authorization and Notification
• Phone: 866-889-8054
• Screening colonoscopy codes: G0105, G0121

Gender dysphoria treatment prior authorization / notification

Notification or prior authorization is required for gender dysphoria treatment procedures; certain CPT codes (e.g., 55970, 55980) require notification/PA when submitted with diagnosis codes F64.x or Z87.890.

• Codes cited for gender dysphoria treatment: 55970, 55980 and various reconstructive CPTs when billed with F64.x or Z87.890
• Policy states PA required for gender dysphoria treatment

Genetic and molecular testing prior authorization

Genetic and molecular testing (including BRCA and other outpatient molecular tests) require prior authorization; the laboratory conducting the test should be notified and UnitedHealthcare should be contacted per the policy instructions.

• Examples of CPT codes listed: 81162–81164, 81228–81229, 81400–81479, 0022U, 0047U, 0087U
• Policy instructs to notify the laboratory and submit PA as directed

Various procedures requiring prior authorization

Prior authorization is required for listed home health non-nutritional services, hysterectomy (inpatient and outpatient where noted), infertility diagnostic and treatment services, and related reproductive services when performed in specified settings; the policy enumerates the applicable CPT/HCPCS codes.

• Home health non-nutritional codes: T1000–T1003 (PA in outpatient settings)
• Hysterectomy and infertility procedure codes listed (e.g., 58267, 58270, 58541–58544, 58550–58573) require PA

Procedure prior authorization (partial list)

Prior authorization is required for numerous outpatient and inpatient abdominal and infertility-related CPT/HCPCS procedures as listed; site-of-service notes apply for screening colonoscopy and other procedures.

• Examples of listed CPTs: 58541–58544 (abdominal procedures), 58345, 58752, 58970 (infertility-related)
• Site-of-service considerations for screening colonoscopy may affect PA requirements

Injectable medications prior authorization (partial list)

An extensive list of injectable medication J-, Q-, and S-codes require prior authorization; submit requests via the Provider Portal (Specialty Pharmacy Transactions tile) or follow the specialty pharmacy submission instructions in the policy. Some codes have place-of-service restrictions.

• Examples include many J-codes (J0256, J0896, J1302, J3385, J0885, J1411–J1414, J3398–J3401, etc.)
• Portal submission: Specialty Pharmacy Transactions tile on UHCprovider.com
• Some codes (e.g., J3385) require PA only for POS 19 and 22

Injectable medications — codes listed and PA instruction

Multiple injectable medication HCPCS/J-codes are listed with instruction that prior authorization is required or how to obtain prior authorization; follow the Provider Portal submission guidance in the policy.

• Listed injectable codes include J3262, J3358, J3380, Q5103, Q5104, Q5121, Q5133, Q5135, J0179, J1552, J1554, J1576, J2508
• Use Provider Portal instructions to submit PA

MRgFUS and non-emergency air transport prior authorization

Prior authorization is required for MR-guided focused ultrasound (MRgFUS) CPT T-codes and for non-emergency air transport/nonurgent ambulance codes; follow the PA submission instructions in the policy.

• MRgFUS CPT T-codes listed: 0071T, 0072T (PA required)
• Non-emergency air transport examples: A0430, A0431, A0435, A0436, S9960, S9961 (PA required)

Inpatient admissions — post-acute services require PA/notification

Prior authorization and notification of the admission date are required for post-acute inpatient services provided in acute care hospitals, acute inpatient rehabilitation, critical access hospitals and long-term acute care hospitals.

• Facilities requiring PA/notification: acute care hospitals, acute inpatient rehab, critical access hospitals, LTACs
• Submit PA/notification per the Provider Portal instructions in the policy

Potentially unproven / experimental services require prior authorization

Services and CPT codes identified as potentially unproven, experimental or investigational require prior authorization before the service is performed.

• Policy labels specified CPT codes (e.g., 26340, 33289, 33361–33366, 33369) as potentially unproven — PA required
• Providers must submit PA per the policy before performing listed services

Orthotics prior authorization threshold: $1,000

Orthotics codes listed require prior authorization only when the retail purchase or cumulative rental cost exceeds $1,000.

• Orthotics examples: L0220, L0482, L0636, L1685, L2036, etc.
• PA required only if retail purchase or cumulative rental cost > $1,000

Facet treatment (Arizona) prior authorization and site-of-service review

For facet treatment procedure codes in Arizona (e.g., 64490–64495), prior authorization is required in all places of service; services will be reviewed for medical necessity and site of service with 'Office' preferred.

• Facet procedure codes: 64490, 64491, 64492, 64493, 64494, 64495 — PA required in Arizona in all POS
• Review will consider medical necessity and site-of-service; 'Office' preferred

Where to get specialty / site-of-service prior authorization information

For specific prior authorization requirements by provider specialty or network status (including site-of-service details), visit myoptumhealthphysicalhealth.com > Tools and Resources as directed in the policy.

• Website for specialty/site-of-service PA details: myoptumhealthphysicalhealth.com > Tools and Resources
• Use the site for provider specialty–specific PA requirements and network status inquiries

Procedures requiring prior authorization (partial list)

Listed procedures identified as 'Potentially unproven services' or otherwise flagged require prior authorization; the policy provides a partial list of such CPT codes and instructs providers to submit PA requests before performing these services.

• Examples of procedures flagged: 26340, 33289, 33361–33366, 33477, 36514, 64722, 52441, 53850, 55874
• Providers should request PA prior to scheduling or performing these services

Prosthetics prior authorization threshold (>$1,000)

Prosthetic HCPCS L-series codes listed require prior authorization only when the retail purchase or cumulative rental cost exceeds $1,000.

• Prosthetic examples: L5010, L5050, L5060, L5100, L5150, L5280, L5301, L5321, etc.
• PA required only if retail purchase or cumulative rental cost > $1,000

Radiation therapy prior authorization

Radiation therapy and associated radiation procedure codes (IGRT, IMRT and others listed) require prior authorization; for some standard radiation therapy codes, PA is required only when billed with certain diagnosis code ranges.

• Examples of radiation therapy codes listed: IGRT 77014, G6017, 77387, 77385, 77386, G6001–G6016
• Some standard radiation therapy codes require PA only when paired with specific cancer diagnosis ranges

ENT procedures (rhinoplasty, sinuplasty) prior authorization and submission instructions

Rhinoplasty and sinuplasty procedures require prior authorization for participating physicians; submit PA requests via the UnitedHealthcare Provider Portal or call the provided prior authorization phone number (866-889-8054).

• Rhinoplasty CPT examples: 30410, 30420, 30430, 30435, 30450, 30460, 30462
• Sinuplasty CPT examples: 31295–31298
• Submission: UHCprovider.com or call 866-889-8054

Site-of-service prior authorization rules (office vs outpatient hospital/ASC)

Site-of-service (SOS) rules apply: services requested in an outpatient hospital or ASC may require prior authorization; PA may not be required if performed at a participating provider and certain states are exempt from SOS PA review as noted in the policy.

• SOS PA required when services requested in outpatient hospital or ASC for specified CPTs
• PA not required if performed by a participating provider in certain states (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, Virgin Islands, Wisconsin)

Prior authorization — CPT/HCPCS code list and SOS notes

The policy lists numerous CPT/HCPCS procedure codes and repeatedly notes 'Site of service (SOS) - outpatient hospital' for screening colonoscopy and other procedures; providers should follow the prior authorization guidance in the policy when submitting requests.

• Screening colonoscopy and many other procedures include SOS = outpatient hospital in the policy code lists
• Follow Provider Portal submission instructions for PA

Colonoscopy screening codes and prior authorization notes

The policy enumerates numerous colonoscopy screening CPT/HCPCS codes and notes that site-of-service (SOS) may apply; providers should consult the policy for code-specific PA and SOS instructions.

• Screening-only and related colonoscopy codes are listed across the policy
• SOS (outpatient hospital) may apply and trigger a site-of-service review during PA

Site of service (outpatient hospital) notes and PA implications

Site-of-service information in the policy specifies 'outpatient hospital' for multiple codes and entries; providers should use the Provider Portal or the phone contacts in the policy when submitting PA and be aware of SOS review exceptions by state.

• Multiple CPTs are labeled with SOS = outpatient hospital in the policy
• State exceptions to SOS review are listed elsewhere in the policy

General prior authorization requirement (all states)

The policy states that prior authorization is required for the listed services for all states.

• General statement: Prior authorization is required for all states for the listed services
• Site-of-service will be reviewed as part of PA with specified state exceptions

Site-of-service review during prior authorization (state exceptions listed)

Site-of-service will be reviewed as part of the prior authorization process for specified codes, except in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin.

• SOS review exceptions: Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands, Wisconsin
• Providers should expect SOS review during PA unless code/state is exempt

Spinal cord stimulators and pharmacy prior authorization

Prior authorization is required for spinal cord stimulators when implanted for pain management; for medications that require pharmacy prior authorization, follow the pharmacy PA contact instructions provided in the policy.

• Spinal cord stimulator implantation for pain requires PA
• Pharmacy PA contact and fax information provided in the policy for medications

Stimulators (non-spine) prior authorization and SOS review

Prior authorization is required for implantation of stimulators (neurostimulators, bone growth stimulators) for all states; site-of-service review applies for listed codes with state exceptions as noted in the policy.

• Neurostimulator and other stimulator implant codes require PA for all states
• Site-of-service review applies; some state exceptions are identified

Therapeutic radiopharmaceuticals — submit PA via Provider Portal

To submit a therapeutic radiopharmaceuticals prior authorization request (and predetermination for nonparticipating outpatient providers), log in to the Provider Portal at UHCprovider.com and sign in at the top-right corner to access submission tools.

• Submit therapeutic radiopharmaceutical PA via UHCprovider.com Provider Portal
• Nonparticipating outpatient providers use predetermination workflow via the portal

VAD and transplant notification workflow — call/fax instructions

For ventricular assist devices (VAD) and certain transplant services, contact the notification number on the member's ID card and follow the call/fax workflow provided; for specified transplants and cellular/gene therapies call 888-936-7246 or the notification number.

• VAD: call the notification number on the member's ID card and fax the form to the Optum VAD Case Management Team
• Transplants/cellular & gene therapies: call 888-936-7246 or the notification number on the member ID card

Neurostimulator implantation codes and prior authorization exceptions

Multiple neurostimulator implantation CPT codes are listed with prior authorization requirements; the policy notes exceptions in specific states and that certain procedure/diagnosis code combinations may not require prior authorization.

• Neurostimulator implantation codes listed (e.g., 61867, 61868, 64555, 64568, 64590, 64595, 64561, 64581)
• Some code/diagnosis combinations (incontinence codes specified) do not require PA
• State exceptions to SOS/PA review are noted in the policy