Prior authorization requirements for STAR Kids
Effective June 1, 2025
This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Kids health care professionals providing inpatient and outpatient services. Please submit your requests in one of the following ways:
- Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. To get started, go to UHCprovider.com and click Sign In at the top-right corner to log in using your One Healthcare ID and password. Then, select the Prior Authorization and Notification tab on your dashboard. If you don't have a One Healthcare ID, visit UHCprovider.com/access.
- Chat: You can also connect with us through chat 24/7 using our Contact us page.
- Fax: 877-940-1972. The fax form is available at Prior Authorization Forms.
Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by a network care provider.
This section lists services, codes, and procedures that require prior authorization or notification for STAR Kids members. The provider must follow the specific instructions shown in the Additional information/How to obtain prior authorization field for each item. Where an item lists a prior authorization effective date, that date is the first date the requirement applies.
Authorization listing (no criteria): The source contains many entries that are catalog-style listings of service categories, CPT/HCPCS codes, and effective dates without detailed clinical decision criteria. Those entries include (but are not limited to) codes and categories under Cardiology, Cardiovascular, Chemotherapy, Cosmetic & Reconstructive, Continuous Glucose, Dental Anesthesia, Durable Medical Equipment (DME), Home Health Care, Outpatient services, Radiology, Psychological Testing, Proton Beam Therapy, Private Duty Nursing, and numerous drug-specific J-/Q-codes and L-codes. Providers should assume these listed codes require prior authorization per the effective dates shown unless otherwise noted. For radiology and advanced imaging please refer to UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources > Radiology Prior for full code lists and submission instructions.
Prior authorization entries and instructions: Consolidated operational instructions and examples from the source are listed below. These apply in addition to the code-level listings above.
How to submit requests: Submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) > Prior Authorization and Notification tab; or via chat on the Contact us page; or via fax to 877-940-1972 using the fax form at Prior Authorization Forms. For transplant and CAR T-Cell therapies contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member ID card as directed in the source.
Genetic and molecular testing / BRCA: Prior authorization or notification is required for genetic and molecular testing performed in an outpatient setting (effective Feb. 1, 2025 for certain BRCA/genetic test CPTs listed). Laboratories and ordering providers must follow the Genetic and Molecular Testing Prior Authorization/Notification program procedures, including indicating the laboratory and test name. Notification/prior authorization is required for BRCA testing before DNA sequencing is performed; the ordering provider must notify the laboratory, and the laboratory will notify UnitedHealthcare.
Cancer supportive care / injectable oncology agents: Prior authorization is required for specified supportive care drugs (e.g., colony-stimulating factors, erythropoiesis-stimulating agents, antiemetics) when billed with oncology diagnosis codes. For these drugs, prior authorization may not be required when billed with non-oncology diagnoses—see the code-level listings and effective dates (example: Oct. 1, 2023). Submit requests via the Provider Portal.
Chemotherapy injectable drugs: Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for oncology diagnoses (effective dates vary by drug/code). This includes IV, intravesical, and intrathecal administration. For drugs without an assigned HCPCS code at time of listing, follow the New to Market / Review at Launch medication process and submit a predetermination when recommended.
Injectable medications (new-to-market drugs): Specific J-/Q-codes listed in the source (examples include J0589, J1411, J2329, J1576, J1747, J2777/J2778, J2351, J0175, Q-codes) require prior authorization with varying effective dates (see code list). UnitedHealthcare uses Optum Specialty Pharmacy/Review at Launch processes for many new-to-market medications; predetermination is highly recommended for those drugs.
Site-of-service (SOS) outpatient hospital vs ASC: Many surgical and procedural codes require prior authorization only when performed in an outpatient hospital setting; the same procedure may not require prior authorization if performed at a participating Ambulatory Surgery Center (ASC). Examples in the source include ear/nose/throat and ophthalmology procedures, colonoscopy, carpal tunnel, cataract surgery, and others. Providers should confirm site-of-service requirements during prior authorization submission.
Durable Medical Equipment (DME) and Medical Equipment (retail/rental threshold): Prior authorization is required for listed DME codes when the retail purchase price or cumulative rental cost exceeds the threshold indicated in the source (example threshold references include $500 in historic entries). Refer to the DME code listings and effective dates for specific codes (examples: E2298, E0639, E0640, E0465, A9900, E0637).
Dental anesthesia: Prior authorization is required for dental anesthesia services billed for members younger than age 21 when billed with modifier U3 (effective July 1, 2017 in source).
Radiology / advanced outpatient imaging: Care providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling the procedure. Many radiology CPTs and MRI/CT codes require prior authorization (effective dates noted, e.g., Jan. 1, 2024). See UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources > Radiology Prior for complete radiology prior authorization code lists and step-by-step submission guidance.
Home Health Care, Private Duty Nursing, PPEC, Wound Vac, and other program-specific services: These categories have code-level listings in the source and may require prior authorization. Examples include home health HCPCS codes (G0299, S9474, G0300, 99503), private duty nursing (T1000), prescribed pediatric extended care services (T1025, T2002, T1026), wound vac supplies (E2402).
Transplant and CAR T-Cell therapy: Prior authorization/notification is required for transplant and CAR T-Cell therapy services (including named products such as Carvykti™, Kymriah™, Yescarta™, Tecartus™). Contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or follow the notification instructions on the member ID card.
Clinical exceptions and diagnosis-dependent rules: Several medication and supply entries are diagnosis-dependent (for example, oncology supportive drugs require oncology DX codes to trigger PA). When the source indicates a diagnosis code dependency, submit the correct primary diagnosis with the authorization request to ensure accurate review.
Effective dates and changes: Many items include an effective date (e.g., Nov. 1, 2016; Feb. 1, 2019; July 1, 2020; Jan. 1, 2024; Jun. 1, 2025). Providers must use the effective date shown for each code/category when determining whether prior authorization is required. When in doubt, include prior authorization submission so services are reviewed before delivery.
Contact and help resources: For radiology-specific prior authorization resources visit UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources > Radiology Prior. For VAD, mechanical pump, and transplant related processes see the source contact numbers (Optum VAD Case Management team at 855-282-8929; Transplant Case Management at 888-936-7246). For specialty drug prior authorization, use Optum SGP or the Review at Launch medication list referenced in the source.
Operational notes (submission tips): - Include the ordering laboratory and test name for genetic/molecular testing prior authorization/notification. - For BRCA and other sequencing tests, ensure laboratory notification processes are followed. - For chemotherapy and infusion drugs, include the oncology diagnosis and regimen details. - For site-of-service reviews, specify the intended facility (outpatient hospital vs ASC). - For DME, include item cost or cumulative rental estimates when applicable.
Denial risk and billing: Failure to obtain required prior authorization may result in denial of payment. Ensure modifier usage (e.g., U3 for dental anesthesia) and correct diagnosis linkage for diagnosis-dependent entries to reduce denial risk.