Prior Authorization Requirements and Submission Procedures
Governs prior authorization submission requirements and lists services and codes that require prior authorization for providers participating with UnitedHealthcare Community Plan of Arizona Complete Care (ACC) Medicaid.
Policy Summary
PayerUnitedHealthcare
PolicyPrior Authorization Requirements and Submission Procedures
Policy CodePolicy N/A
Change TypeNo material changes
Effective Date
Next Review Date
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com using One Healthcare ID or by phone at 800-445-1638.
No material clinical or coverage changes in this revision.
Portal & phoneRequest methods
UHCproviderPortal
800-445-1638Prior auth phone
ExperimentalExclusions
Many servicesAdult (21+) rule
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Coverage Criteria and Requirements
Coverage criteria and exceptions (partial)
High-level coverage criteria and notable exceptions:
Services must be AHCCCS-covered to be eligible for prior authorization.
Only medically necessary, cost‑effective, federally‑ and state‑reimbursable services are covered per AHCCCS definitions.
Only one health care professional may request services on a prior authorization request form.
Services provided by non‑network and out‑of‑state providers require prior authorization with supporting documentation.
Experimental and investigational services are not covered benefits (prior authorization required for services considered experimental for members 21 and older).
Age-based exception: Allergy immunotherapy and allergy testing: for members younger than 21 these are covered under EPSDT when medically necessary; for members 21 and older allergy immunotherapy (including desensitization treatments) is not a covered benefit.
Inpatient video EEG coverage rules
Cerebral seizure monitoring — inpatient video EEG:
Prior authorization is required for inpatient video EEG (cerebral seizure monitoring).
Prior authorization is not required for outpatient hospital or ambulatory surgical center video EEG services.
Prior authorization is required for injectable chemotherapy drugs administered in an inpatient setting associated with these services.
Circumcision coverage rules
Circumcision coverage rules:
Routine circumcision is not a covered benefit.
Prior authorization is required for circumcision only when medical necessity is documented.
DME coverage and authorization
Durable medical equipment (DME) prior authorization:
Prior authorization is required for the listed DME codes when retail purchase or cumulative rental cost exceeds $500.
Preferred Homecare is the primary vendor for many DME items; for items not covered by Preferred Homecare review the Provider Manual for contracted vendors and submission routing.
Cochlear implant coverage rules
Cochlear and other auditory implants:
Prior authorization is required for cochlear and other auditory implants; clinical documentation must accompany the request to establish medical necessity.
For members younger than 21, prior authorization is required for supplies, equipment maintenance and repair; hardware components may be non‑covered.
Age-based PA criteria excerpts
Age‑based prior authorization guidance:
Members <21: Refer to AHCCCS AMPM Chapter 400 Section 430 (EPSDT) for coverage of services such as oral nutritional supplements; certain services (e.g., allergy testing/immunotherapy, selected genetic or hearing services) may be covered without adult PA restrictions when medically necessary.
Members >=21: Prior authorization is required for many listed services and codes for members 21 and older, including services considered experimental or investigational; see AMPM Chapter 300 references.
Enteral/parenteral nutrition: Requests for enteral/parenteral/oral in‑home nutritional therapy must include clinical documentation and a certificate of medical necessity and are routed to Preferred Homecare (contact information provided in the document).
Prior authorization requirement (age 21+)
Ophthalmic procedures (members 21 and older):
Prior authorization is required when medically necessary to diagnose or treat diseases and conditions of the eye for the listed CPT/HCPCS codes (examples include 58275, 58280, 58285, 58290, 58291).
Adult (21+) prior authorization and routing requirements (partial)
Adult (21+) prior authorization and vendor routing (partial):
Prior authorization is required when medically necessary for the listed CPT/HCPCS and injectable medication codes for members 21 and older (ophthalmic and other procedures shown).
Incontinence supplies are a benefit only when provided through Preferred Homecare; provider must request supplies via Preferred Homecare contact provided.
Infusion in‑home services and injectable medications not covered by Optum Infusion require prior authorization; requests for services/medications are routed to Optum Infusion per document instructions.
Injectable medications examples: Numerous injectable medications and associated J‑codes listed require prior authorization (examples provided in the document).
Summary prior authorization criteria
Summary prior authorization criteria and process:
Notification and prior authorization are required for inpatient admissions to acute care hospitals, acute inpatient rehabilitation and long‑term acute care hospitals.
Orthognathic and maxillofacial/jaw functional procedure codes listed require prior authorization and admission notification as noted.
Numerous drug HCPCS/J‑codes and unclassified/temporary codes listed require prior authorization; the document refers providers to the Review at Launch and to submit per the plan process.
Submit prior authorization requests online via the UnitedHealthcare Provider Portal (sign in with One Healthcare ID) or call the plan phone number provided (document lists 888‑397‑8129 as an alternative).
Prior authorization and admission requirements
Prior authorization and admission notification requirements:
Notification of the admission date is required for acute care hospitals, acute inpatient rehabilitation and long‑term acute care hospitals.
Prior authorization is required for the CPT/HCPCS codes listed in this section; unclassified/temporary codes (e.g., C9094, C9149) are specifically noted in the prior authorization instructions.
Providers should submit prior authorization requests online via the UnitedHealthcare Provider Portal (One Healthcare ID) or call the plan phone number referenced in the document.
Orthotics/Prosthetics and Inpatient Admission Prior Authorization Criteria
Orthotics and prosthetics and inpatient admission prior authorization:
Prior authorization is required for many orthotics/prosthetics HCPCS L‑codes listed; documentation must establish medical necessity and coverage is subject to AHCCCS/Medicare guidance.
AHCCCS orthotics coverage applies when the orthotic is medically necessary and consistent with Medicare guidelines; age‑related coverage and repair vs replacement guidance are noted.
Cost/rental consideration: Repair may be preferred if repair cost is less than replacement; purchase vs rental and cost thresholds (retail purchase or cumulative rental cost considerations) are factors in authorization decisions.
Prior authorization and notification of admission date are required for inpatient admissions to acute care hospitals, acute inpatient rehabilitation and long‑term acute care hospitals.
Outpatient occupational and physical therapy (members <21)
Outpatient occupational and physical therapy (members <21):
For members younger than 21, outpatient occupational and physical therapy are covered when medically necessary with no annual benefit limits, but prior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing therapy visits.
Outpatient speech therapy
Outpatient speech therapy:
For members younger than 21, outpatient speech therapy is covered when medically necessary with no annual benefit limits; prior authorization is required after the initial evaluation and before the initial therapy visit and for all ongoing visits.
For members 21 and older, outpatient speech therapy is not a covered benefit per the document.
Out-of-state / Out-of-network services
Out‑of‑state and out‑of‑network services:
Prior authorization is required for all out‑of‑network services.
Out‑of‑state services are approved only when emergent or when the service is unavailable in the state of Arizona.
Pharmacy and specialty drug prior authorization
Pharmacy and specialty drug prior authorization:
Specific specialty medications and physician‑administered biologic/biotech drugs listed in the document require prior authorization; clinical documentation and, where applicable, the Certificate of Medical Necessity must accompany the request.
Pharmacy prior authorization requires submission per the plan's pharmacy PA process (document lists pharmacy PA contact information and that J‑codes and NDCs must be provided).
New/temporary codes: Unclassified and temporary HCPCS/CPT codes (e.g., C9094, C9149) and new‑to‑market medication review processes are referenced and may require special handling per plan policies.
Authorization applicability
Authorization applicability notes:
Prior authorization is required for codes listed under skilled nursing as indicated in the ophthalmologic/other mappings.
Prior authorization is required for listed sleep apnea procedures and codes.
Prior authorization is required for many listed CPT/HCPCS codes for ophthalmologic and spinal surgery services; the document presents multiple code mappings and indicates requirement language for listed codes (examples include 65426, 65730, 65855, 66170).
Mapping note: Multiple HCPCS or alternate CPT mappings (e.g., E0291–E0294, 22112, 22210, etc.) are shown as cross‑references for certain codes and reflect the mapping information in the list.
Prior authorization requirements (partial)
Prior authorization requirements (partial):
Prior authorization is required for listed sterilization and related reproductive procedure codes (examples: 52601, 52630, 52647, 52648, 52649); for members younger than 21 prior authorization is required as noted.
Prior authorization is indicated for numerous spinal surgery CPT codes listed in the document (examples include 22548, 22551, 22800–22861, 63001–63308, etc.).
Prior authorization coverage requirements (partial, by service)
Prior authorization is required for transplant and CAR T‑cell therapy services; providers should contact the UnitedHealthcare Community and State Transplant Case Management team as directed in the document.
Prior authorization is required for sterilization CPT codes; for members younger than 21 the document explicitly requires prior authorization.
Prior authorization and notification processes are required for ventricular assist device (VAD) services; providers must follow the notification and fax instructions to Optum VAD Case Management.
Prior authorization is required for non‑emergent transportation services (e.g., taxi, stretcher van); scheduling via Medical Transportation Management (MTM) is noted.
Prior authorization is required for wound VAC code E2402.
Range of L-codes present in source (examples: L6882, L6883, L6884, L6885, L6895, etc.)
Provider Submission, Routing, and Contact Instructions
Prior Authorization
How to request prior authorization
This list contains prior authorization requirements for health care professionals participating with UnitedHealthcare Community Plan of Arizona Complete Care (ACC) Medicaid. To request prior authorization, submit your request using one of the following: Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with your One Healthcare ID and password. Phone: 800-445-1638
Prior Authorization
General prior authorization requirements and limitations
Prior authorization is required for services to be eligible only when they are covered benefits under AHCCCS. Services by non-network or out-of-state providers require prior authorization with supporting documentation. Experimental/investigational services are not covered. All rendering providers, facilities and vendors must be actively registered with AHCCCS. Only one provider may request services per prior authorization form. Only medically necessary, cost-effective, federally- and state-reimbursable services are covered per AHCCCS. For members under age 21, certain EPSDT provisions apply (for example, allergy testing/immunotherapy coverage differs by age).
Prior Authorization
Examples of services and codes requiring prior authorization
Selected services and example codes that require prior authorization (consolidated — not exhaustive). For complete lists and details, refer to the Provider Portal Prior Authorization tool and plan resources.
Allergy immunotherapy/testing — see AHCCCS/EPSDT rules (varies by age)
Augmentative and alternative communication — examples: 92607, 92608, 92609; HCPCS: E2500, E2502, E2504, E2506, E2510, E2511, E2512, E2599, V5336
Cancer supportive services / injectable colony‑stimulating factors — e.g., filgrastim and pegfilgrastim biosimilars (Q5108, Q5111, Q5120, Q5122 etc.) and certain J‑codes; outpatient administration requires prior authorization
Cardiology — outpatient diagnostic catheterizations, electrophysiology implants and stress echoes require prior authorization (see portal and program resources)
Cerebral seizure monitoring — inpatient video EEG and related CPTs: 95700–95726 series (examples 95700, 95711–95716, 95720–95726); inpatient services require prior authorization
Chemotherapy injectable drugs — many J‑codes, miscellaneous HCPCS Q/C codes and non‑assigned agents billed under J3490/J9999 require prior authorization; intravesical/intrathecal routes for cancer diagnoses require authorization
Circumcision — routine circumcision not covered; prior authorization required only for medically indicated cases (examples: 54161, 54162)
Cochlear and other auditory implants — examples: CPTs 69710, 69714, 69930; HCPCS L8614, L8619, L8690, L8692 (prior authorization required; clinical documentation required; supplies/maintenance may require authorization)
For injectable chemotherapy and other specialty drug prior authorization: submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the number below for guidance. For chemotherapy agents not yet assigned a HCPCS code and billed under miscellaneous codes, submit the clinical information via the portal or call the provider line.
For chemotherapy/injectable oncology drugs and coding questions contact the Provider Portal prior authorization tool or call 800‑445‑1638 (or specialty numbers provided in individual sections)
For transplant and CAR T‑cell therapies contact UnitedHealthcare Community and State Transplant Case Management Team at 800‑418‑4994
Prior Authorization
Circumcision prior authorization
Routine circumcision is not a covered benefit. Prior authorization is required only for cases with documented medical indication. Example CPT codes: 54161, 54162.
Prior Authorization
Cochlear and auditory implants prior authorization
Cochlear and other auditory implants require prior authorization. For members younger than 21 some services/supplies may be covered under EPSDT without prior authorization; for members 21+, prior authorization and clinical documentation are required. Example codes: 69710, 69714, 69930, L8614, L8619, L8690, L8692. Clinical documentation must accompany requests; hardware limited coverage rules apply.
Prior Authorization
DME prior authorization and vendor information
Durable medical equipment (DME): Preferred vendors and ordering instructions — prior authorization required for listed HCPCS E‑codes and other DME when retail purchase or cumulative rental exceeds $500. For items not covered by Preferred Homecare, review the Provider Manual for contracted vendors at UHCprovider.com/AZcommunityplan. To request DME services/products through Preferred Homecare or to verify coverage, contact Preferred Homecare at 800‑636‑2123.
Enteral / parenteral / oral in‑home nutritional therapy (enteral feeds, gastrostomy tube supplies, TPN and lipids, oral supplements) requires prior authorization and must include clinical documentation and, when applicable, a Certificate of Medical Necessity. To request services and/or supplies, call Preferred Homecare at 800‑636‑2123.
Prior Authorization
Experimental/investigational services and adult prior authorization requirement
Experimental and investigational services for members 21 and older require prior authorization. Refer to AHCCCS AMPM Chapter 300 (Policy 320‑B and related sections) for details on criteria and required documentation. Examples of codes referenced in experimental/linked services are included in the Provider Portal resources.
Prior Authorization
Selected service codes referenced
Selected procedure and CPT/HCPCS groupings referenced across this section — providers must use the Provider Portal for full code tables and up‑to‑date lists. The following are representative examples pulled from the detailed policy:
Orthotics/prosthetics L‑codes: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0640, L0700–L0710, many others (see portal)
Note
Request prior authorization / vendor contact
To request incontinence supplies or DME through Preferred Homecare call Preferred Homecare at 800‑636‑2123. For infusion and in‑home injectable services or medications not covered by Optum Infusion, call Optum Infusion at 888‑705‑4470. For radiology prior authorization and advanced imaging resources, use the Provider Portal or call 866‑889‑8054. For transplant and CAR T‑cell therapies, contact the Transplant Case Management Team at 800‑418‑4994.
Prior Authorization
Pharmacy prior authorization process
For pharmacy prior authorization (including specialty pharmacy), contact UnitedHealthcare Pharmacy Prior Authorization Service: Phone 800‑310‑6826; Fax 866‑940‑7328. Fax forms and pharmacy PA resources are available on UHCprovider.com/AZcommunityplan under Pharmacy Resources and Physician‑Administered Drugs.
Prior Authorization
Transportation prior authorization
Non‑emergent medical transportation (taxi, stretcher van) requires prior authorization. To schedule transportation, call Medical Transportation Management (MTM) at 888‑700‑6822.
Prior Authorization
Wound VAC prior authorization
Wound VAC: Prior authorization is required for E2402.
E2402
Definitions and Vendor Notes
Covered benefits (AHCCCS alignment)
RequirementCovered services must align with Arizona Health Care Cost Containment System (AHCCCS) definitions and reimbursement rules
EligibilityOnly medically necessary, cost-effective, federally- and state-reimbursable services per AHCCCS are eligible for prior authorization
Network ruleServices by non-network or out-of-state providers require prior authorization with supporting documentation
ExclusionServices determined to be experimental and/or investigational are not covered benefits
Adult PAFor members 21 and older, prior authorization is required for services considered experimental/investigational
ReferenceSee AMPM Chapter 300 Section 320-B for details on services with special circumstances
UHC Provider Portal submission
Primary channelUnitedHealthcare Provider Portal Prior Authorization and Notification tool (sign in with One Healthcare ID)
Portal accessGo to UHCprovider.com and click Sign In in the top-right corner to use One Healthcare ID
Phone alternativePhone numbers for portal/PA assistance: 888-397-8129 (documented as portal phone option); 800-445-1638 referenced elsewhere for PA requests
Circumcision (coverage exception)
Coverage stanceRoutine circumcision is not a covered benefit
ExceptionPrior authorization is required only for circumcision cases with documented medical necessity
Example codesCPT codes listed in doc: 54161, 54162
Certificate of Medical Necessity (enteral/oral supplements)
RequirementCertificate of Medical Necessity and clinical documentation must accompany requests for enteral/parenteral/oral in‑home nutritional therapy
Vendor contactTo request services/supplies call Preferred Homecare at 800-636-2123
ScopeApplies to enteral via gastrostomy, TPN and/or lipids, and oral supplements
Experimental and investigational services (definition & PA)
InterpretationServices labeled experimental/investigational are not covered and require prior authorization for members 21 and older
ProcessRefer to AMPM Chapter 300 (Policy 320-B) for review criteria and documentation requirements
ImplicationClinical documentation must justify medical necessity for services otherwise considered investigational
Prior authorization (ophthalmic procedures, members 21+)
ScopePrior authorization is required for listed ophthalmic CPT/HCPCS codes when medically necessary to diagnose or treat diseases and conditions of the eye for members 21 and older
Example codesCodes explicitly listed include 58275, 58280, 58285, 58290, 58291 (document repeats these for ophthalmic PA)
Site noteSome ophthalmologic entries include site-of-service (SOS) annotations relevant to PA determinations
Vendor-specific benefits and authorization routing
Vendor routingIncontinence supplies are covered only when provided through Preferred Homecare; to request call 800-636-2123
Infusion routingInfusion and in‑home injectable services/medications not covered by Optum Infusion require prior authorization and requests should be made via Optum Infusion at 888-705-4470
ImplicationCertain benefits are vendor-specific and must follow designated vendor authorization channels
Prior authorization (definition & submission)
DefinitionPrior authorization: required approval from the plan before certain procedures, admissions, equipment, or drug administration will be covered
Submission optionsSubmit via UnitedHealthcare Provider Portal (One Healthcare ID) or by phone (888-397-8129); some services have vendor-specific phone numbers
Applies toListed CPT/HCPCS codes, unclassified/temporary codes (e.g., C9094, C9149), inpatient admissions and many J‑codes
Unclassified and temporary HCPCS/CPT codes guidance
GuidanceFor unclassified and temporary HCPCS/CPT codes (e.g., C9094, C9149), follow the document instructions — these codes may require prior authorization
ExamplesUnclassified codes referenced include C9094 and C9149 listed in multiple sections
Process noteSubmit PA requests for unclassified codes via the Provider Portal or by phone per standard submission channels
Portal accessUnitedHealthcare Provider Portal — sign in with One Healthcare ID to submit prior authorization requests (Prior Authorization and Notification tool)
Phone alternativeIf portal access not available, call 888-397-8129 as documented for PA assistance
Lab contactFor certain laboratory prior authorizations, contact Labcorp at 800-788-9743 (documented alongside portal instructions)
Facility types requiring admission notification
FacilitiesAcute care hospitals, acute inpatient rehabilitation, and long-term acute care hospitals require admission notification and prior authorization for inpatient admissions
Notification detailNotification of admission date is required for these facility types as part of the admission process
Submission methodUse the UnitedHealthcare Provider Portal or call 888-397-8129 to submit notifications and prior authorization requests
Prior authorization process summary
SummaryProviders must obtain prior authorization for many listed outpatient/inpatient procedures and for admissions; submit requests online via the Provider Portal or by phone
IncludesApplies to listed CPT/HCPCS codes, unclassified/temporary codes, and certain drug/J-codes
Admission noteAdmission notification required for acute care, acute inpatient rehab, and long-term acute care hospitals
AHCCCS orthotics coverage summary
AHCCCS ruleAHCCCS orthotics coverage applies when the orthotic is medically necessary and consistent with Medicare guidelines
PA for L-codesPrior authorization is required for many HCPCS L‑codes related to orthotics and prosthetics; purchase vs rental and retail/cumulative cost considerations apply
DocumentationMedical necessity documentation is required; repair may be preferred if repair cost is less than replacement
Site of service (SOS)
DefinitionSite of service (SOS) annotations map codes to the location where the procedure is performed (e.g., outpatient, hospital, skilled nursing, specialty)
SOS impactSOS can affect whether prior authorization is required (e.g., some services require PA only when performed in outpatient setting)
ExamplesSinuplasty and selected arthroscopy codes include SOS notes in the document indicating PA applicability
J-codes / NDC requirement
RequirementFor physician‑administered medications, include J‑codes and NDC codes when requesting prior authorization
Pharmacy PA contactsUnitedHealthcare Pharmacy Prior Authorization Service Phone: 800-310-6826; Fax: 866-940-7328; specialty PA fax: 866-940-7328
ScopeApplies to pharmacy-administered and select J‑code injectable medications listed in the policy
Site of service (SOS) annotations
UsageSite of service (SOS) annotations indicate where a CPT/HCPCS code is typically performed and can modify PA requirements
ExamplesDocument shows SOS mapping for ophthalmologic codes and notes that PA may apply differently by site
ImplicationVerify SOS when submitting PA to ensure correct routing and justification
Prior authorization (explicit statement)
Explicit requirementPrior authorization is required for certain settings (e.g., skilled nursing) and for listed procedure groups (e.g., sleep apnea procedures)
ExamplesSkilled nursing entries note 'Prior authorization is required'; sleep apnea procedures listed with PA requirement
ActionObtain PA prior to service; follow site-specific and code-specific instructions in the document
Prior authorization (short)
Short definitionPrior authorization is required approval before coverage of specified services, procedures, or admissions
How to submitUse UnitedHealthcare Provider Portal (One Healthcare ID) or call 888-397-8129; some services require vendor-specific contacts
Applies toCPT/HCPCS codes, J‑codes, unclassified codes, and inpatient admissions listed throughout the policy
Prior authorization (definition across code lists)
DefinitionPrior authorization is the requirement to obtain approval from the plan before performing the listed procedures/codes (noted throughout CPT/HCPCS lists)
ApplicationThis definition applies across multiple code lists in the document (ophthalmologic, spinal, orthognathic, etc.)
Provider implicationProviders should obtain PA per plan rules for codes enumerated in the policy prior to scheduling or performing services
Ventricular assist device (VAD) definition
DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle of the heart
PA & notificationPrior authorization is required for listed VAD codes; providers must call the notification number on the member's ID card and fax the nurse‑provided form to the Optum VAD Case Management Team
Code examplesDocument references VAD CPT ranges (e.g., 33927–33983) and HCPCS Q0507–Q0509 in relation to PA
Policy Summary
PayerUnitedHealthcare
PolicyPrior Authorization Requirements and Submission Procedures
Policy CodePolicy N/A
Change TypeNo material changes
Effective Date
Next Review Date
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com using One Healthcare ID or by phone at 800-445-1638.
Unclassified and temporary codes (e.g., C9094, C9149) are referenced and require prior authorization handling per document instructions.
Enteral/parenteral/oral in‑home nutritional therapy (enteral, gastrostomy, TPN/lipids, oral supplements) — request via Preferred Homecare at 800‑636‑2123; clinical documentation and certificate of medical necessity required
Experimental/investigational services (members 21+) — prior authorization required; refer to AHCCCS AMPM Chapter 300 policies and attachments for requirements and specific CPT/HCPCS examples
Genetic testing (members 21+) — selected CPTs require prior authorization: examples include 81405, 81415, 81460, 81479, 81321, 81403, 81407 and cytogenetic/molecular codes 88245–88285 series and others
Hearing services / hearing aids (members 21+) — selected audiology CPTs/HCPCS require prior authorization: 92590–92595, 92592–92594 and HCPCS V‑codes V5010–V5252 (for members under 21 some services are covered without prior authorization)
Home health care — prior authorization required for listed codes (examples: G0299, G0300, V5267, V5298, S9123, S9124)
Incontinence supplies — benefit only when provided through Preferred Homecare; example HCPCS codes and requests through Preferred Homecare at 800‑636‑2123
Infusion and in‑home injectable services — prior authorization required for services not covered by Optum Infusion; request through Optum Infusion at 888‑705‑4470
Injectable medications — many J‑codes require prior authorization (examples listed in pharmacy/specialty sections); for pharmacy prior authorization contact UnitedHealthcare Pharmacy PA Service: Phone 800‑310‑6826, Fax 866‑940‑7328
Joint replacement / total hip — prior authorization required for listed CPTs (e.g., 27130 and related codes) and inpatient admission notification requirements apply
Laboratory services — selected labs require prior authorization; refer to portal and policy details
Out‑of‑network and out‑of‑state services — prior authorization required for out‑of‑network services; out‑of‑state services covered only when emergent or unavailable in Arizona
Outpatient therapy (members <21 and others) — prior authorization required after initial evaluation and before ongoing visits for OT/PT; CPT examples 97113, 97530, 97116, 97535, 97124, 97140, G0281
Pharmacy / physician‑administered drugs — many J‑codes and miscellaneous codes require PA; representative J‑codes in this policy include J0224, J0717, J1290, J1299, J1303, J1427, J1428, J1429, J1786, J2326, J2357, J3060, J3385, J3398, J3399; contact Pharmacy PA for details
Prostate procedures, proton beam therapy, rhinoplasty/septoplasty, reproductive/sterilization procedures, transplant services, VAD/ventricular assist devices and many surgical specialties — prior authorization required for listed CPT/HCPCS codes (refer to the detailed code lists in the Provider Portal and policy resources)
Radiology — advanced outpatient imaging (certain CT/MRI/MRA/PET and nuclear medicine/cardiology) requires prior authorization; ordering clinicians must notify prior to scheduling; use the Provider Portal or call 866‑889‑8054
Skilled nursing / inpatient admissions / post‑acute facilities — prior authorization and admission notification required for acute care hospitals, inpatient rehab, LTACH and other listed facilities; certain procedure codes associated with admissions require authorization
Site‑of‑service mapping and many additional CPT/HCPCS codes across surgical, musculoskeletal, ophthalmologic, urologic, ENT, GI and other categories are listed in the detailed provider resources — see Provider Portal for full coded lists and submission guidance
Wound VAC — prior authorization required for HCPCS E2402
Radiology advanced imaging: certain CT/MRI/MRA/PET and nuclear medicine studies — see Radiology Prior Authorization and Notification Program at UHCprovider.com/AZcommunityplan
Spinal surgery and major musculoskeletal CPTs: 22513, 22515, 22532–22533, 22548, 22551, 22554–22558, 22600–22633, 22800–22899, 63001–63191, 63200–63286 and many others
Transplant / CAR T therapies: contact UnitedHealthcare Community and State Transplant Case Management Team at 800‑418‑4994 for authorization and coordination