Rocky Mountain Health Plans Medicare Advantage / D‑SNP Prior Authorization and Notification Requirements
Lists prior authorization and notification requirements (including submission methods and example CPT/HCPCS/ICD-10 codes) for participating and non-participating providers serving UnitedHealthcare Rocky Mountain Health Plan Medicare Advantage and Dual-Special-Needs Plan members.
Policy Summary
PayerUnitedHealthcare
PolicyPrior Authorization and Notification Requirements for Rocky Mountain Health Plans Medicare Advantage and D‑SNP
Policy CodePolicy N/A
Change TypeNo material change
Effective DateNov 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or use delegated vendor portals/phone numbers (eviCore for many radiology and cardiology services).
No material clinical or coverage changes in this revision.
3submission methods listed
emergencyemergency exceptions
20+distinct codes shown
~300+code listings in excerpt
Prior authorization required
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Prior authorization and notification requirements — overarching policy: many outpatient and inpatient services require prior authorization or notification for participating and non‑participating providers. Requests may be submitted via the UnitedHealthcare Provider Portal, by fax (non‑participating providers), or through delegated vendors such as eviCore. Prior authorization is not required for emergency or urgent care.
General submission methods: Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using a One Healthcare ID; non‑participating providers may fax requests and documentation to 800‑262‑2567 or 970‑255‑5681. eviCore managed services: submit at evicore.com or call 800‑792‑8750. Behavioral health services: call 888‑282‑8801. Notification by admitting facility: phone 800‑416‑2157 (option 4) or 970‑248‑5197.
Scope: Participating providers and non‑participating providers must obtain prior authorization or provide notification for many specified outpatient and inpatient services unless care is emergent or urgent.
Delegation note: Certain clinical areas (for example, radiology and cardiology) are managed by eviCore — notification/prior authorization required for both participating and non‑participating providers through eviCore.
Provider responsibility: Out‑of‑network physicians, facilities and other providers must request authorization for all procedures and services except emergent or urgent care. Prior authorization requirements apply to inpatient and outpatient settings as indicated in the service lists.
Partial list of services and supplies requiring prior authorization or notification. This is a consolidated, non‑exhaustive list pulled from the source document. Providers must consult specialty‑specific prior authorization pages (and eviCore where delegated) for full code lists and clinical criteria.
Cardiology: Notification/prior authorization required for outpatient and office‑based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiograms. Certain cardiology services are managed by eviCore (see eviCore for full list). Example codes referenced: 33206–33229, 33270, 33274, 33289.
DME and HCPCS code annotations — selected codes listed with prior authorization requirement noted. Providers should verify through the Provider Portal or DME prior authorization resources for complete lists and documentation requirements.
Durable medical equipment examples requiring prior authorization include (not exhaustive): A4265 (DME), A4556–A4558, E0265–E0303, E0290–E0297, E0300–E0303, E2374–E2394, E0720, E0730, E0744–E0770, E0748–E0765, E0764–E0770, K0857–K0864, K0861–K0864, L3000–L3100 series (orthotics/prosthetics), L8694–L8695, and other E/K/L series HCPCS codes. See specialized DME prior authorization processes for details.
Codes requiring prior authorization — consolidated listing of notable CPT/HCPCS ranges and exemplar codes. This list consolidates the partial entries from the source; it is not exhaustive. Providers must reference specialty‑specific prior authorization instructions and delegated vendor lists (eviCore) for complete code sets and clinical criteria.
Cardiology and electrophysiology: 33206–33229, 33270, 33274, 33289, 93799, 94799, 39599.
Submit prior authorization and notification requests using one of the following methods. Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (go to UHCprovider.com, Sign In with One Healthcare ID, then select Prior Authorization and Notification). Non‑participating providers: Fax request and documentation to 800‑262‑2567 or 970‑255‑5681. eviCore (cardiology/radiology and some specialty review): Submit via evicore.com portal or call 800‑792‑8750. Behavioral health: Call 888‑282‑8801. Admitting facility notifications: Call 800‑416‑2157, option 4 or 970‑248‑5197. Prior authorization is not required for emergency or urgent care. Out‑of‑network providers must request authorization for all procedures and services except emergent/urgent care.
Admitting facility notification: 800‑416‑2157 (opt 4) or 970‑248‑5197
Non‑participating provider fax: 800‑262‑2567 or 970‑255‑5681
Prior Authorization
eviCore‑managed cardiology prior authorization
Terminology & Notes
Prior authorization except emergency or urgent care situations
DefinitionPrior authorization is a requirement to obtain approval before performing certain services, except in emergency or urgent care situations.
Applies toParticipating and non‑participating providers delivering inpatient and outpatient services to UnitedHealthcare Rocky Mountain Health Plan Medicare Advantage and D‑SNP members.
ExceptionPrior authorization is not required for emergency or urgent care.
eviCore‑managed services (examples)
DefinitioneviCore‑managed services are services for which prior authorization and notification are delegated to eviCore (examples include many cardiology procedures and many radiology services).
How to obtainSubmit requests to eviCore online at evicore.com or by phone at 800‑792‑8750 for delegated services.
Policy Summary
PayerUnitedHealthcare
PolicyPrior Authorization and Notification Requirements for Rocky Mountain Health Plans Medicare Advantage and D‑SNP
Policy CodePolicy N/A
Change TypeNo material change
Effective DateNov 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or use delegated vendor portals/phone numbers (eviCore for many radiology and cardiology services).
Infusions and injections: Prior authorization required for many infusion/injection services (example CPT 96379 and numerous injectable HCPCS/J‑codes).
Medical and surgical supplies: Prior authorization required for many Q‑codes and supply codes (examples: Q4103–Q4124, Q4256–Q4258).
Medicine procedures and services: Prior authorization required for selected medicine procedure codes (examples: 95199, 99183, 99199, 97602, 97605–97610).
Musculoskeletal / Orthognathic / Maxillofacial surgery: Prior authorization required for many related CPT codes (examples: 21029, 21076–21089, 21497, 26556, 29868, 21141–21172).
Nasal / ENT procedures and sleep disorder treatment: Prior authorization required for certain rhinoplasty, sinuplasty and sleep disorder procedure codes (examples: 30400–30468, 31295–31298, 41512, 41530, 41599).
Radiation therapy and radiology: Prior authorization required; many radiology services and advanced imaging are managed by eviCore. Examples include radiation therapy codes 32701, 77299, 77373, 77399, 77435, 77499, 77520–77525, 77605, 77620, 77799, G0339–G0340 and radiology codes 70300–70355, 70450–70487, 70480–70487, 75573, 76120–76125, 76496–76499, 76978–76979.
Respiratory procedures: Prior authorization required for many respiratory procedure codes (examples: 31641, 31647–31651, 31660–31661, 31899, 32994–32999).
Spine surgery and stimulators: Prior authorization required for numerous spine procedure and neurostimulator codes (examples: 20930–20931, 20999, 22505, 22533–22558, 22585, 22590, 22595, 22600–22634, 22856–22870, 62263–62264, 63001–63035, 63185–63200, 63250–63285, neurostimulator codes 20974–20975, 61850–61888, 63650–63688, 64553–64595).
Transplants: Prior authorization required for transplant procedures (examples: 32850–32856, 33930).
Transportation: Prior authorization required for non‑emergent transport services (examples: A0430, A0435, A0436).
Urological, uterine, vein procedures and wound care: Prior authorization required for various codes in these service categories (examples: 0499T, 36465–36470, 57292–57426, G0277, G0329, skin substitute Q‑codes such as Q4276, Q4311–Q4321).
New/temporary technology and certain Category III/T/U codes: Many new, temporary, and other unproven technology codes are flagged and may require prior authorization or clinical review (examples: 0014M, 0015M, 0062U–0066U, 0068U, 0077U, 0080U, 0086U, 0091U–0096U, 0109U, 0112U, 0152U–0155U, 0202U, 0223U, 0225U, 0253T, 0255U, 0259U).
Cardiology services listed below are delegated to eviCore for prior authorization/notification. Participating and non‑participating providers must submit requests to eviCore via their portal (evicore.com) or phone (800‑792‑8750). Typical cardiology CPT/HCPCS examples requiring eviCore review include pacemaker/implantable devices, electrophysiology and advanced diagnostic catheterization codes (examples shown; this is not an exhaustive list).
eviCore submission required for delegated cardiology services
The following cardiovascular, DME/HCPCS, K‑series DME, enteral supplies, gastroenterology, select surgical (including gender dysphoria and orthognathic), genetic/lab tests, and orthotics/prosthetics (L‑codes) require prior authorization or notification as indicated. Submit requests via UnitedHealthcare Provider Portal or the delegated vendor (eviCore) where noted. Codes shown are representative and consolidated from the policy source — review payer/vendor instructions for the full code list.
Genetic/laboratory tests and molecular panels: Prior authorization required for extensive list of CPT/HCPCS and proprietary test codes. Selected ranges include 81162–81167, 81173–81176, 81185–81190, 81215–81239, 81248, 81299–81337, 81346–81364, 81400–81407, 81435–81471, 81479–81595, and many U‑/T‑/M‑series and G‑series genetics codes and proprietary lab (U‑codes, 03xxU)
Orthotics/prosthetics (L‑codes) requiring prior authorization: Extensive L‑code list in source (selected examples): L1499, L3000–L3070, L3100–L3465, L3500–L5999, L6000–L6999, and many intermediate L‑code ranges; submit prior authorization for devices, custom orthotics, prosthetic components, and major assemblies
New, emerging, or potentially unproven technologies (U‑, T‑ and some M‑series codes) are flagged and require review/authorization. These codes may be treated as investigational or require additional clinical documentation; submit via the portal and include supporting clinical evidence. Examples include many U‑codes and T‑codes listed in the source (e.g., 0014M, 0015M, 0062U–0068U, 0077U, 0080U, 0086U, 0091U–0096U, 0109U, 0112U, 0152U–0155U, 0202U, 0223U, 0253T, 0255U, 0259U, 0261U, 0263U, 0275T, 0321U, 0345T, 0379T, 0398T, 0403T, 0419T–0421T, 0437T, 0443T, 0446T–0450T, 0470T–0471T).
U/T/M‑series codes flagged as potentially unproven or investigational — prior authorization required
Provide supporting clinical evidence and rationale with submission
Use UnitedHealthcare Provider Portal; for services delegated to eviCore follow their submission instructions
Prior Authorization
Transportation prior authorization
Transportation services (non‑emergent) require prior authorization. Examples of transport HCPCS codes that require prior authorization are listed below. Submit transport authorization requests through the Provider Portal.
Scope examplesCardiology CPT examples listed in the document (e.g., 33206–33231, 93451–93462) and multiple radiology CPT/HCPCS codes are noted as managed by eviCore.
notification/prior authorization required
MeaningNotification/prior authorization required indicates providers (participating and non‑participating) must obtain prior authorization or provide notification to the administrator (UnitedHealthcare or delegated vendor eviCore) before performing the listed service.
Radiology noteMany radiology CPT/HCPCS codes require notification or prior authorization and are delegated to eviCore for submission and review.
Submission methodsUse UnitedHealthcare Provider Portal or eviCore portal/phone depending on delegation; phone numbers and portal URLs are provided in the document.
Continuous glucose monitor (CGM)
DefinitionContinuous glucose monitor (CGM) refers to CGM devices and associated HCPCS device codes (document lists E2102, E2103 and A4238).
Authorization stanceContinuous glucose monitors are marked 'Prior authorization required' in the list.
Example codesE2102, E2103, A4238 (CGM device HCPCS codes listed).
'Additional information' as used in entries
Meaning'Additional information' in entries indicates supplemental notes tied to a code (for example clarifying authorization status or other instructions).
UsageEntries may include 'Additional information' to state 'Prior authorization required', specify settings, or reference related documentation.
Location examplesMultiple HCPCS and DME entries include 'Additional information' fields alongside codes (see E‑ and K‑code listings).
'how to obtain authorization prior' meaning
MeaningPhrases like 'how to obtain authorization prior' indicate that the code requires the payer's prior authorization process and list where/how to submit requests.
InstructionsThese entries direct providers to the appropriate submission method (UnitedHealthcare Provider Portal, fax for non‑participating providers, or delegated vendor like eviCore) as applicable.
ExamplesMany HCPCS E‑ and K‑code entries include 'how to obtain authorization prior' guidance in the document sections cited.
Prior authorization required (reference)
Definition'Prior authorization required' or 'Prior authorization' indicates the listed procedure or code requires approval before services are rendered.
Applies toApplies to a wide range of codes and services across specialties (e.g., DME, genetic tests, radiology, surgical procedures) listed in the document.
Provider obligationProviders must request and obtain authorization using the specified submission channels prior to service (except in emergencies).
Genetic test/lab services requiring authorization
DefinitionGenetic test and proprietary laboratory services listed (811xx–815xx and U‑codes) require prior authorization before service.
ExamplesExtensive CPT genetic test codes (e.g., 81162–81479, 81500–81595) and proprietary U‑codes (e.g., 0001U, 0317U–0344U) are listed as requiring authorization.
ActionProviders must follow the document's prior authorization instructions for genetic/lab tests; some entries note 'how to obtain authorization prior'.
Prior authorization (reference)
DefinitionPrior authorization: obtain approval from UnitedHealthcare (or delegated vendor) before performing certain services; submission via Provider Portal or phone/fax as specified.
ExceptionNot required for emergency or urgent care.
U-code (proprietary lab code) explanation
DefinitionU‑code (proprietary lab code) refers to CPT Category IIs/Category I‑like proprietary laboratory test codes (U‑series) that represent specific lab or molecular tests and may require authorization.
ContextU‑codes appear alongside genetic/molecular test CPT codes in the authorization sections for lab services.
Unclassified and temporary codes examples (C91-C9399, J3490, J3590)
DefinitionUnclassified and temporary codes (e.g., C91‑C9399, J3490, J3590) are listed as requiring prior authorization; specific product names billed under these codes may also require authorization.
ExamplesDocument explicitly states prior authorization is required for unclassified/temporary codes and lists C91‑C9399, J3490, J3590 as examples.
Associated productsThe section cites product examples (Amvuttra, Beqvez, Roctavian, etc.) subject to prior authorization when billed under unclassified/temporary codes.
Q4xxx medical and surgical supplies
DefinitionQ4xxx codes represent medical and surgical supplies (Q4xxx series) and are listed in the document as requiring prior authorization.
ExamplesMultiple Q4xxx/Q41xx/Q43xx entries appear in the Medical and Surgical supplies and Wound care/skin substitute sections with authorization required.
ActionProviders must obtain prior authorization for Q4xxx supply codes as indicated in the list before supplying these products.
Orthognathic
DefinitionOrthognathic refers to corrective jaw (maxillofacial) surgery CPT codes; the document lists multiple orthognathic CPT procedure codes as requiring prior authorization.
ExamplesSample orthognathic CPT codes listed include 21248, 21249, 21255, 21256, 21295–21299 and related maxillofacial procedure codes.
Provider actionObtain prior authorization for orthognathic CPT codes before scheduling or performing surgery as indicated in the list.
Orthotics and prosthetics (L-codes)
DefinitionOrthotics and prosthetics (L‑codes) are HCPCS codes for prosthetic and orthotic devices; numerous L‑codes in the document are listed as subject to prior authorization.
ExamplesDocument lists many L‑codes (e.g., L1499, L3000–L3100, and an extensive L‑code range) that require prior authorization.
How to obtainEntries direct providers to 'how to obtain authorization prior' instructions for L‑codes in the orthotics/prosthetics section.
'Prior authorization required' meaning (reference)
Meaning'Prior authorization required' or 'Prior authorization' indicates that listed procedures or codes require approval before services are rendered; providers must follow the documented authorization process.
ScopeThis flag applies across many sections (pain management, radiology, genetic tests, DME, surgical procedures) in the document.
Exception reminderEmergency and urgent care services remain exempt from prior authorization requirements per the document's general guidance.
'Potentially' or 'unproven' flags for temporary/new tech codes
Definition'Potentially' or 'unproven' flags are used to denote new, temporary, or emerging technology codes (U/T/M‑series) that may be considered investigational or require additional review and authorization.
ExamplesDocument lists multiple U‑, T‑, and M‑series codes (e.g., 0014M, 0062U, 0064U, 0253T, 0345T) accompanied by 'Potentially' or 'unproven' notes and authorization requirements.
ImplicationThese flags indicate higher review scrutiny and that authorization may be required or authorization criteria may be stricter for such codes.
Notification/prior authorization required for providers
DefinitionNotification/prior authorization required for providers means participating and non‑participating providers must obtain authorization or notify UnitedHealthcare or delegated vendors before performing listed services.
Radiology delegationMany radiology services require notification/prior authorization and are managed by eviCore; providers should use eviCore's submission portal or phone as instructed.
Provider remitNon‑participating providers may fax requests to the specified fax numbers where indicated; admitting facilities have a specific notification phone line.
Authorization submission methods (UnitedHealthcare portal and phone)
MethodsUnitedHealthcare Provider Portal (Prior Authorization and Notification tool at UHCprovider.com) — primary online submission method.
Phone/fax optionsUnitedHealthcare phone: 800‑666‑1353; non‑participating provider fax: 800‑262‑2567 or 970‑255‑5681.
Delegated vendorFor delegated services, submit via eviCore at evicore.com or call 800‑792‑8750; behavioral health requests via 888‑282‑8801.
Prior authorization (reference)
DefinitionPrior authorization indicates approval must be obtained before performing the listed service or billing the listed code; failure to obtain prior authorization may affect coverage or payment.
Where statedThe document marks many service categories and specific CPT/HCPCS codes across sections with 'Prior authorization' or 'Prior authorization required'.
Exceptions and delegationEmergency/urgent care are exceptions; some services are delegated to eviCore and require submission to that vendor as noted.