CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for STAR+Plus

This document lists prior authorization requirements and submission instructions for health care professionals participating in UnitedHealthcare Community Plan STAR+PLUS (Texas). It governs how and when prior authorization must be requested for inpatient and outpatient services for STAR+PLUS members.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for STAR+Plus

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal, by phone at 877-842-3210, or by fax to 877-940-1972.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-06-01policy effective date shown on title

Online/Phone/Faxprior authorization submission methods listed

Many codesdocument contains extensive code-level requirements

HCPCS J/Qdrug codes referenced

Phone providedcontact for prior authorization

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Prior Authorization Coverage Criteria

inv-01: Prior authorization stance and criteria

The document specifies that many listed services and codes require prior authorization; specifics vary by code, diagnosis, and effective date.

Prior authorization is required for many outpatient and inpatient services and specific CPT/HCPCS/J/Q codes listed in this document; some codes require prior authorization only when billed with oncology or other specified diagnosis codes while others require prior authorization regardless of diagnosis.

Prior authorization is not required for emergency or urgent care.

Prior authorization requests may be submitted via the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification), by phone (877-842-3210), or by fax (877-940-1972); some services list alternative phone numbers for authorization.

inv-02: Prior authorization criteria for listed codes

Prior authorization requirements and effective dates for specific codes

Prior authorization is required for the listed J- and Q-codes (examples include J9177, J9246, J9198, J9358, Q5119, Q5117, Q5107).

Some of these drug/J-code entries include explicit effective dates for the prior authorization requirement (examples in the document include July 1, 2020 and Oct. 1, 2020).

For many of the listed oncology drug codes prior authorization must be obtained by calling the number shown in the listing (document references 'for prior authorization, please call').

inv-03: Code-level prior authorization listings

Document lists codes and associated prior authorization dates; no clinical coverage criteria or detailed requirements are present in these chunks.

The document provides code-level listings and effective dates for prior authorization (for example entries show Oct. 1, 2020 and July 1, 2020 for select codes).

Many entries are code-focused and do not include clinical coverage criteria in these excerpts; operational instructions (how to obtain prior authorization) are provided where present.

inv-04: Prior authorization stance for listed J‑codes

Prior authorization requirements indicated for specific HCPCS J‑codes; some entries include effective dates and notes on how to obtain prior authorization (e.g., phone call).

Selected HCPCS J-codes and related chemotherapy/infused drug codes are listed as requiring prior authorization; some entries include effective dates (examples: Oct. 1, 2019; Jan. 1, 2019; Aug. 1, 2019).

The listings note that chemotherapy injectable drugs without assigned codes billed under miscellaneous HCPCS will require prior authorization.

inv-05: Cosmetic / Reconstructive Procedures — PA and skin cancer exception (partial)

Cosmetic and reconstructive CPT codes appear with prior authorization rules and a skin-cancer exception noted.

Multiple cosmetic and reconstructive CPT codes are listed with prior authorization entries (examples include 14020, 14021, 14041, 14061, 15820, 17106, 21137).

The document repeatedly states that many cosmetic/reconstructive procedures will NOT require prior authorization when billed with skin cancer diagnosis codes (skin cancer exception appears across the listings).

inv-06: J‑codes, Continuous Glucose Monitors, Incontinence supplies (partial)

Drug, device, and DME prior authorization requirements for select items (injectables, CGMs, incontinence supplies).

Certain injectable medications require prior authorization; some oncology injectable codes require authorization for oncology and non-oncology diagnoses with specified submission routes (Provider Portal or phone).

Continuous glucose monitor devices and supplies (e.g., A4238, A4239, E2102, E2103, A9276, A9278) require prior authorization effective Feb. 1, 2023.

Incontinence supplies require prior authorization through the service coordinator when not provided by the designated vendor; contact numbers are listed for Tenderheart Health Outcomes and service coordinator routing.

inv-07: FAI, FESS, gender dysphoria, and experimental services — PA required (partial)

Surgical procedures and potentially experimental services are listed with prior authorization requirements.

Femoroacetabular impingement (FAI) arthroscopic procedure codes (29914, 29915, 29916) have prior authorization effective Oct. 1, 2015.

Sinus surgery (FESS) and related endoscopic procedure codes are listed and the document states prior authorization is required for these codes with any diagnosis in the excerpts shown.

Entries include various surgical and other high-acuity or experimental procedure codes with prior authorization noted; effective dates and additional instructions appear for some items in the broader listing.

inv-08: Partial authorization criteria statements

Authorization stance for listed codes (partial):

Codes listed under Femoroacetabular Impingement Syndrome (29914, 29915, 29916) have prior authorization noted (effective Oct. 1, 2015).

Sinus surgery/FESS and related endoscopic codes are listed with the statement 'prior authorization is required for these codes with any DX.'

Gender dysphoria code rules

Gender dysphoria and related treatment codes (examples: 55970, 56805, 57335, 55980) are listed as requiring prior authorization.
The document alternately states 'prior authorization is required for these codes with any DX' and 'prior authorization is only required for these codes with these DX', indicating that some gender dysphoria codes have conditional prior authorization dependent on the diagnosis coding or other context elsewhere in the full policy.

inv-09: Genetic/molecular testing criteria (excerpt)

Genetic and molecular testing performed in outpatient settings require prior authorization/notification; BRCA testing requires notification before sequencing.

Prior authorization is required for genetic and molecular testing performed in an outpatient setting; providers must complete the prior authorization/notification process and indicate the laboratory and test name.

Notification/prior authorization is required for BRCA testing before DNA sequencing; the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

inv-10: Surgical codes for gender dysphoria (excerpt)

Examples of procedural prior authorization language for gender dysphoria surgical codes.

Certain surgical codes used in gender dysphoria treatment (example codes 56805, 57335) are included in the listing; the document indicates prior authorization is required for these codes in the contexts shown and that some entries are conditional on associated diagnosis codes.

inv-11: Injectables prior authorization (excerpt)

Many injectable medications are listed as requiring prior authorization; Review at Launch guidance referenced for new-to-market drugs.

Numerous injectable medications and related HCPCS/J-codes are listed as requiring prior authorization; examples and effective dates are provided for select products and groups.

Providers are advised to check the Review at Launch for New to Market Medications and pre-determination is highly recommended for drugs on that list; prior authorization routes (Optum, OptumRx) are referenced for some agents.

inv-12: Prior authorization criteria (excerpt)

Prior authorization requirements described in this excerpt include:

Orthotics and prosthetics require prior authorization for all STAR+PLUS members; multiple L-codes are enumerated in the listing and some entries show an effective date (Jan. 1, 2019).

Long-Term Services and Supports (LTSS)/HCBS require prior authorization effective Jan. 1, 2015 and involve a centered care planning process (assessment and determination of needs).

Ground ambulance services are listed with a Texas mandate and prior authorization effective April 1, 2016 for specified ambulance codes.

For certain new injectable medications the policy cites specific prior authorization effective dates (examples include Apr. 1, 2024 for a named product) and recommends checking Review at Launch guidance for submission and pre-determination.

inv-13: Coverage criteria for listed services

Prior authorization requirements and notes for listed services and codes as provided in these chunks:

Ground ambulance and LTSS/HCBS transport codes require prior authorization (ground ambulance effective Apr. 1, 2016; LTSS/HCBS effective Jan. 1, 2015) and include routing/centered-care planning notes.

Orthognathic surgery procedure codes are listed with a prior authorization field present in the listing (no explicit date visible in these excerpts).

Extensive orthotics and prosthetics L-code group is listed and the document states prior authorization is required for STAR+PLUS members; some entries note WAIVER plan members require prior authorization regardless of billed amount.

inv-14: Per-code prior authorization stance

Prior authorization requirements and notes for listed services/codes

The document lists numerous outpatient and therapy CPT/HCPCS codes and indicates which codes require prior authorization; some categories (e.g., outpatient services) have effective dates (example: July 1, 2017) and instructions to use the Prior Authorization and Notification tool on UHCprovider.com for submission.

Operating room revenue-coded services have a prior authorization effective date of Jan. 1, 2015 and include a nursing-facility-only restriction in the revenue-code section.

inv-16: Prior authorization requirements (excerpt)

Notices and brief coverage/authorization rules shown in the excerpt (partial):

Prior authorization is required for nursing facilities only for specified OR revenue codes as noted in the revenue-code section (effective Jan. 1, 2015).

Care providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling; radiology prior authorization/notification has submission instructions (Provider Portal or call 866-889-8054).

Psychological testing prior authorization was noted with an effective date Oct. 1, 2019 and the document indicates prior authorization will not be required for dates of service on or after March 1, 2022 per the listing.

citations":[

Codes and Code Groups Subject to Prior Authorization

EEG / Oncology Injectable HCPCS/J CodesHCPCS

J9324	HCPCS code listed for EEG / oncology injectables
J9029	HCPCS code listed for EEG / oncology injectables
J9058	HCPCS code listed for EEG / oncology injectables
J9063	HCPCS code listed for EEG / oncology injectables
J9322	HCPCS code listed for EEG / oncology injectables
J9347	HCPCS code listed for EEG / oncology injectables
J9380	HCPCS code listed for EEG / oncology injectables
J9274	HCPCS code listed for EEG / oncology injectables

Additional EEG / Oncology HCPCS/J Codes (excerpt)HCPCS

J9064	Related HCPCS code from section
J9052	Related HCPCS code from section
J9172	Related HCPCS code from section
J9258	Related HCPCS code from section
J9321	Related HCPCS code from section
J9056	Related HCPCS code from section
J9059	Related HCPCS code from section
J9259	Related HCPCS code from section
J9323	Related HCPCS code from section
J9350	Related HCPCS code from section

1–10 of 12

1/2

Chemotherapy / Oncology Misc HCPCSHCPCS

J9274	Also appears in chemotherapy code lists (included above)
J9331	Chemotherapy related HCPCS code listed nearby
J9298	Chemotherapy related HCPCS code listed nearby
J9332	Chemotherapy related HCPCS code listed nearby

How to Submit Prior Authorization Requests and Provider Responsibilities

Prior Authorization

How to Submit Prior Authorization Requests

You can request prior authorization in one of the following ways: Online: Use the UnitedHealthcare Provider Portal. Go to UHCprovider.com and click Sign In in the top-right corner. Then, select Prior Authorization and Notification on your provider portal dashboard. Phone: 877-842-3210 Fax: 877-940-1972. The fax form is available at UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources > Prior Authorization Forms. Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by an InNetwork provider for all procedures and services, excluding emergent or urgent care.

Provider Portal: UHCprovider.com → Sign In → Prior Authorization and Notification
Phone: 877-842-3210
Fax: 877-940-1972 (fax form at UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources > Prior Authorization Forms)
Emergency/urgent care: PA not required
Out-of-network requests must be made by an InNetwork provider (except emergent/urgent care)

Prior Authorization

Injectable Medications: Prior Authorization and Review-at-Launch Guidance

Definitions and Policy Notes

Prior authorization request submission methods and exemptions

Submission methodsOnline via UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification), by phone (877-842-3210), or by fax (877-940-1972)

Emergency/urgent care exemptionPrior authorization is not required for emergency or urgent care

Out-of-network requestsOut-of-network prior authorization requests must be made by an in-network provider except for emergent or urgent care

Prior authorization is a required approval process

DefinitionPrior authorization is a required approval process prior to coverage for the listed codes

How to obtainFor specified J- and Q- codes prior authorization instructions include calling the number listed in the code entry (document lists contact instructions)

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for STAR+Plus

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal, by phone at 877-842-3210, or by fax to 877-940-1972.

SourceLink

On This Page

Certain injectable and infused medications require prior authorization. Many injectable medications are routed through Optum (or the specified pharmacy/vendor) and are subject to the Review at Launch program for newly approved drugs. For newly marketed drugs on the Review at Launch Medication List, pre-determination is highly recommended. Check the Review at Launch for New to Market Medications policy at UHCprovider.com → Menu → Policies and Protocols → Community Plan Policies → Medical & Drug Policies and Coverage Determination Guidelines for Community Plan for the most current list and submission instructions.

Injectable medications generally require prior authorization; specific codes and effective dates are listed in the policy code table.
Optum routing: many specialty/infused drugs require prior authorization through Optum (contact numbers are provided with the specific drug listings).
Review at Launch: newly FDA-approved drugs may be on the Review at Launch Medication List — pre-determination recommended.
Examples of drugs on the list (selection, not exhaustive): Eylea HD®, Izervay®, Acthar Gel®, Hemgenix®, Leqembi®, Briumvi®, Panzyga®, Cimerli™, Rolvedon™, Spevigo®, Tzield™, Xenpozyme™. Follow the policy for exact submission routing and effective dates.

Prior Authorization

Orthotics and Prosthetics: Repeated L-code Group Entries

Extensive lists of L-codes for orthotics and prosthetics are subject to prior authorization where indicated. The document contains repeated grouped entries for L-code ranges (for example L5631/L5645/L5637/L5647 and many other L-code groups). Providers should reference the orthotics & prosthetics section for the complete code lists and follow the prior authorization instructions for STAR+PLUS and WAIVER plan members as applicable.

Repeated L-code groups: L5631, L5645, L5637, L5647 (and many additional L-code groupings) are enumerated in the policy — treat these groupings as requiring the listed PA rules when indicated.
Orthotics & Prosthetics PA: Prior authorization is required for all STAR+PLUS members (and for WAIVER plan members regardless of billed amount where noted).
How to obtain PA: see Orthotics and Prosthetics section and submit via Provider Portal or the contact indicated in the orthotics/prosthetics listing.

Prior Authorization

Operating Room Revenue Codes: Prior Authorization Required

Prior authorization is required when operating room (OR) services are billed with certain revenue codes. This requirement became effective Jan. 1, 2015. When services are billed with the listed OR revenue codes, obtain prior authorization before scheduling (nursing-facility-specific exceptions are noted).

OR revenue codes that trigger PA include: 419, 420, 421, 422, 423, 424, 429, 430, 431, 432, 433, 434, 439, 440, 441**, 441**, 977 (see policy for full list and context).
**Prior authorization required for nursing facilities only for certain revenue codes.
Effective date: Jan. 1, 2015.

Denial Risk

Potentially Unproven Services: Prior Authorization

Some services and procedures are considered potentially unproven and require prior authorization when billed. Providers should obtain prior authorization for these services per the effective dates listed in the policy.

Examples of potentially unproven services: CPT 33289 and HCPCS C2624.
Effective date for listed potentially unproven services: Apr. 1, 2023.
How to obtain PA: follow the same submission routes (Provider Portal, phone, fax) and reference the specific code entry in the policy for any required documentation.

Prior Authorization

How to Obtain Prior Authorization / Notification (Radiology)

Advanced outpatient imaging and other radiology services require prior authorization/notification before scheduling. Providers must follow the radiology prior authorization and notification process on the Provider Portal or call the radiology notification number.

Obtain radiology prior authorization/notification via the UnitedHealthcare Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or call the radiology prior authorization number listed in the radiology section.
Specific radiology CPT/HCPCS codes subject to PA are listed in the Radiology section of the policy (e.g., advanced imaging codes 70460–70543 series, 78469–78483, 70480–70496 etc.).
Refer to Radiology Prior Authorization and Notification Resources at UHCprovider.com/TXCommunityPlan > Prior Authorization and Notification Resources > Radiology Prior Authorization and Notification for code lists and submission details.
For scheduling: do not schedule advanced outpatient imaging until PA/notification requirements are met.

Prior Authorization

Ventricular Assist Device (VAD): Prior Authorization

Ventricular Assist Device (VAD) implantation and related services require prior authorization. Providers should contact Optum VAD Case Management for the authorization process and use the provided forms and fax number.

VAD CPT/HCPCS codes: 33975, 33976, 33979, 33981, 33982, 33983, Q0507, Q0508 (see policy for full code mapping).
Prior authorization effective date: Jan. 1, 2015.
How to obtain PA: contact the Optum VAD Case Management team. Fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929. Also call the number on the member's plan ID card or the State Transplant/Case Management contact where indicated.
Documentation: include clinical rationale, device details, and pre/post-operative plan as requested by VAD Case Management.

Coverage implicationServices/drugs listed without prior authorization will not be covered until authorization is obtained per the document

Prior Authorization — definition

Short definitionPrior authorization: a payer approval process required before certain services or drugs will be covered

IncludesApplies to listed CPT/HCPCS codes and certain services per the document (see code listings)

SubmissionRequests submitted via Provider Portal, phone, or fax as directed in the policy

Prior authorization requirement explanation

Requirement explanationCertain HCPCS J‑codes and other listed codes require prior authorization; effective dates for some entries are specified (examples include July 1, 2020; Oct. 1, 2020; Jan. 1, 2023)

Diagnosis dependencySome codes require prior authorization regardless of diagnosis while others have diagnosis‑specific requirements (see code entries)

Provider actionFollow Additional Information/How to Obtain Prior in each code entry for submission instructions and effective dates

DME prior authorization threshold

$500 threshold rulePrior authorization is required only when a listed DME has a retail purchase cost or cumulative rental cost greater than $500

Prosthetics noteProsthetics are not classified as DME for this threshold — see Orthotics & Prosthetics section

Effective datesSome DME entries include effective dates (e.g., April 1, 2019) — check specific code rows for dates

Provider Portal submission or phone — oncology route

Oncology submission routeOncology prior authorization requests should be submitted online via the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling the oncology phone line 888-397-8129 as noted

ScopeApplies to oncology J-codes and related drug entries (document lists examples such as J1950 and other J-codes)

Non-oncology casesFor non-oncology diagnoses, follow the Injectable Medications section instructions (per code-specific notes)

Prior authorization requirement (any DX)

Any-diagnosis PA requirement'Prior authorization is required for these codes with any DX' indicates listed procedure codes must be authorized regardless of diagnosis

Example codesApplies to certain sinus surgery/FESS and related endoscopic codes (e.g., 31256, 31276, 31288) as shown

Provider actionObtain authorization before scheduling regardless of diagnosis coding for these entries

Conditional prior authorization (specific DX)

Conditional PA'Prior authorization is only required for these codes with these DX' indicates authorization is required only when the listed procedure codes are paired with specific diagnosis codes

ExampleGender dysphoria treatment codes (e.g., 56805, 57335) are listed with language that alternately specifies any‑DX or DX‑specific prior authorization — check the associated diagnosis code field

ActionConfirm diagnosis pairing in the code row to determine whether PA is required for the procedure

BRCA testing — PA/notification requirement

BRCA testing notificationNotification/prior authorization is required for BRCA testing before DNA sequencing is performed; ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare

ProcessProviders must complete the Genetic and Molecular Testing prior authorization/notification process, including indicating the laboratory and test name

ApplicabilityApplies to genetic and molecular testing performed in an outpatient setting (codes such as 81520 referenced)

Review at Launch — definition/reference

Review at Launch definitionUnitedHealthcare's Review at Launch for New to Market Medications: a list of newly approved drugs that may require prior authorization; providers should check the list and pre-determine when recommended

Recommended actionPre-determination is highly recommended for drugs on the Review at Launch list

Where to findPolicy and list available at UHCprovider.com under Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines

Review at Launch — short reference

Short referenceReview at Launch — UnitedHealthcare list of new‑to‑market medications for which pre‑determination and prior authorization guidance apply

UseProviders should consult the list for up‑to‑date prior authorization requirements on newly approved drugs

LTSS/HCBS care planning — definition

LTSS/HCBS care planningLTSS/HCBS prior authorization requires a centered care‑planning process that includes assessment and determination of needs

Effective datePrior authorization noted effective Jan. 1, 2015 for LTSS/HCBS entries

ApplicabilityApplies to Long‑Term Services and Supports/Home‑and‑Community‑Based Services code group listed in the document

WAIVER plan members — note

WAIVER plan notePrior authorization is required for all WAIVER plan members regardless of billed amount for certain orthotics and prosthetics entries

ContextWAIVER‑specific requirement appears in the Orthotics & Prosthetics section (chunk 145)

ActionFollow WAIVER member instructions in the orthotics/prosthetics code rows when applicable

STAR+PLUS members — definition/reference

STAR+PLUS membersPrior authorization requirements in this document apply to STAR+PLUS members (Texas Community Plan)

Orthotics & ProstheticsPrior authorization is required for orthotics and prosthetics for all STAR+PLUS members (see L‑code listings)

ScopeDocument governs prior authorization for inpatient and outpatient services for STAR+PLUS members

Prior Authorization and Notification tool (UHCprovider.com)

Tool referencePrior Authorization and Notification tool available on the UnitedHealthcare Provider Portal (UHCprovider.com) — use Prior Authorization and Notification on the portal dashboard to submit or notify

Radiology notePortal is also referenced for radiology prior authorization/notification submissions (see radiology entries)

Where to accessAccess via UHCprovider.com → Sign In → Prior Authorization and Notification on Provider Portal dashboard

Potentially Unproven Services — definition

Potentially Unproven Services'Potentially Unproven Services' is a category in the document listing codes that require prior authorization (effective Apr. 1, 2023 for listed entries)

ExamplesIncludes codes such as 33289 and C2624 listed under Potentially Unproven Services

ActionObtain prior authorization for codes in this category before providing services

Prior authorization — general reference

General PA referencePrior authorization/notification: approval process required before certain services or drugs will be covered; follow submission instructions in the document

Radiology-specificCare providers ordering advanced outpatient imaging must provide notification prior to scheduling; use Provider Portal or call 866-889-8054

Submission channelsPortal, phone, fax options described in the policy apply to general prior authorization and notification

Site of Service (SOS) - Outpatient Hospital — definition

SOS - Outpatient Hospital rulePrior authorization is required when requesting a service in an outpatient hospital setting; not required if performed at a participating (in‑network) facility

Effective datesSome site‑of‑service outpatient hospital entries show effective dates (example: July 1, 2020) — check specific code rows

Provider actionConfirm site of service before requesting authorization; if outpatient hospital, obtain PA per instructions

Ventricular Assist Device (VAD) — definition

VAD definitionVentricular Assist Device (VAD): a mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow

CodesRelevant VAD procedure codes listed include 33975, 33976, 33979, 33981, 33982, 33983 and related Q‑codes (Q0507, Q0508)

Prior authorizationVAD procedures require prior authorization; contact the Optum VAD Case Management team for authorization details