CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for Texas CHIP

Lists services, codes, and submission instructions for prior authorization required for UnitedHealthcare Community Plan Texas CHIP providers for inpatient and outpatient services; applies to participating health care professionals and providers submitting authorizations for Texas CHIP members.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Texas CHIP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Aug 1, 2024policy effective date

877-842-3210authorization phone

877-940-1972authorization fax

866-604-3267oncology prior auth contact

~200+distinct HCPCS/CPT codes listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services and Codes Requiring Prior Authorization

Oncology and supportive care prior authorization

Oncology injectable medications and supportive care agents

Colony stimulating factors, erythropoiesis stimulating agents, antiemetic supportive care agents and other oncology injectables require prior authorization when billed with an Oncology diagnosis code; prior authorization is not required for these codes when billed with non-oncology diagnoses (see provider portal submission instructions).

For chemotherapy injectable drugs billed under miscellaneous or unclassified HCPCS (e.g., J‑codes without assigned permanent codes), prior authorization is required and providers should contact the oncology prior authorization line (call 866-604-3267) or submit via the UnitedHealthcare Provider Portal as directed for Oncology DX submissions.

Cardiology prior authorization

Cardiology and cardiovascular procedures

Outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiography require prior authorization prior to performance for participating physicians; submit requests via the UnitedHealthcare Provider Portal.

Certain cardiovascular procedures require prior authorization for members age 18 and older.

Prior authorization code list (partial)

Code-level prior authorization listing (partial) — this segment lists J- and Q-codes that require prior authorization (no additional clinical criteria provided in this extract).

The following J- and Q-codes are included in the prior authorization listing (partial): J9118, J9223, J9144, J9281, J9316, J9317, J9227, J9304, Q5107, Q5117, J9177, J9246, J9198, J9358, J0642, J9309, J9119, J9204, J9210, J9269, J9030, J9036, J9229, J9057, J9214, J9216, J9213, J9218, J9230, J9228, J9245, J9261, J9263, J9260, J9262, J9266, J9268, J9264, J9267, J9271, J9280, J9295, J9301, J9293, J9299, J9303, J9306, J9302, J9305.

Codes and special rules (partial list)

Selected codes and special rules (partial list)

Cochlear implant procedure codes (e.g., 69729, 69730) require prior authorization with an effective date noted in the listing (March 1, 2023).

Durable medical equipment (DME) entries on the list require prior authorization only for codes where the retail purchase or cumulative rental cost exceeds $500; prosthetics are not considered DME (see orthotics/prosthetics section).

High-level prior authorization requirements (partial)

Genetic and molecular testing performed in an outpatient setting requires prior authorization/notification; the ordering provider must indicate the laboratory and test name as part of the prior authorization/notification process.

A large set of injectable and specialty medication HCPCS/J/Q codes require prior authorization; some entries reference submission via Optum SGP or OptumRx processes and 'Review at Launch' guidance for newly approved medications (pre-determination is recommended).

Procedural and DME categories are listed with prior authorization effective dates where specified; some procedures are flagged as experimental/investigational and have effective dates noted in the listing.

Prior authorization requirement list (codes and items)

Prior authorization is required for the listed services and codes. Some entries include effective dates; consult the payer for full clinical criteria and 'Review at Launch' guidance for new drugs.

Unclassified injectable medications (example: Rivfloza billed to C9399/J3590/J3490) require prior authorization effective July 1, 2024; providers should consult the Review at Launch policy and consider pre-determination.

Replacement joint procedures (total hip and knee) and associated CPT/HCPCS codes require prior authorization (effective Jan. 1, 2015).

Orthognathic surgery procedure codes and transport/related codes require prior authorization (effective Jan. 1, 2015); orthotics/prosthetics items with retail purchase or cumulative rental cost over $500 require prior authorization.

Selected coverage/prior authorization notes

Examples and selected notes from the listing

Therapy and evaluation codes: 97542 is noted with an asterisk indicating prior authorization is not required in at least one context (marked '*').

Radiology: advanced outpatient imaging procedures require notification prior to scheduling; submit via the UnitedHealthcare Provider Portal or call the number provided in the listing.

Psychological testing: prior authorization is referenced with effective/expiration date notes; prior authorization will not be required for dates of service on or after March 1, 2022 for the listed psychological testing entries.

Outpatient hospital prior authorization rule

Site-of-service requirement for prior authorization

Prior authorization is required when requesting listed services in an outpatient hospital setting (Site of Service - outpatient hospital); the list identifies the procedures and subcategories for which this site-of-service authorization applies.

Extracted coverage requirements (fragment)

Extracted coverage requirements and operational contacts (fragment)

Spinal surgery codes listed require prior authorization; site of service will be reviewed as part of the prior authorization process.

Implantable stimulator and bone growth device implantation codes (including E0747/E0748 and select spinal stimulator codes) require prior authorization with effective dates noted (examples: Jan. 1, 2015; Dec. 7, 2015).

Transplant and CAR T-Cell therapy services require prior authorization; providers should contact the State Transplant Case Management Team at 888-936-7246 or the notification number on the member's health plan ID card for coordination and notifications.

Ventricular Assist Device (VAD) procedures listed require prior authorization (effective Jan. 1, 2018); instructions reference the member ID card notification number and faxing required forms to Optum VAD Case Management.

Code Tables and Coding Notes

Chemotherapy J-/Q- Codes (selected) - require prior authorization per oncology DXHCPCSCovered

J9227	Chemotherapy agent (example)
J9304	Chemotherapy agent (example)
Q5107	Supportive care biologic (Q-code)
Q5117	Supportive care biologic (Q-code)
J9177	Chemotherapy agent
J9246	Chemotherapy agent
J9198	Chemotherapy agent
J9358	Chemotherapy agent
J9119	Chemotherapy agent
J9204	Chemotherapy agent

1–10 of 16

1/2

Selected Injectable Medications (mixed specialty examples) - neutral/managedHCPCS

J9332	Therapeutic biologic (example)
J1551	Leqvio® (injectable)
J2998	Cutaquig ® / immunoglobulin product
J7352	Scenesse®
J9331	Specialty biologic

Note

Provider Action / Billing Rule

Prior authorization is required for many oncology and specialty injectable medications when billed with oncology diagnosis codes; for some drugs prior authorization is required regardless of diagnosis. Submit requests using the UnitedHealthcare Provider Portal or call the designated prior authorization number where noted.
Affected codes include numerous J- and Q-codes listed in the coding tables above (e.g., J1442, J1447, J0897, J2777, J0225, J1554, J9202, J9312, Q5124, Q5130, J9227, J9304).

How to Submit Authorizations and Operational Contacts

Prior Authorization

Outpatient hospital prior authorization note

Prior authorization is required only when the listed procedure or service is requested in an outpatient hospital setting (site of service = outpatient hospital). When requesting such services, please submit prior authorization requests via the UnitedHealthcare Provider Portal or contact the number shown for the specific service. Site-of-service reviews are performed as part of the prior authorization for applicable procedures; authorization may be denied or redirected if the requested setting is not supported. Emergency and urgent care services remain exempt from prior authorization requirements.

Submit outpatient hospital prior authorization requests online: UHCprovider.com > Provider Portal > Prior Authorization and Notification.
Or call the applicable prior authorization phone number listed elsewhere in this section (e.g., 866-889-8054 for advanced outpatient imaging; 866-604-3267 for oncology chemotherapy injectable drugs).
Provide site-of-service information when submitting requests so the review can determine whether the outpatient hospital setting is appropriate.
Out-of-network requests must be made by an in-network provider (except for emergent or urgent care).

Terms and Field Definitions

Prior authorization — definition & exceptions

DefinitionPrior authorization is a required approval process for specified inpatient and outpatient services before performance; it is not required for emergency or urgent care

Submission channelsRequests may be submitted online via the UnitedHealthcare Provider Portal, by phone (877-842-3210), or by fax (877-940-1972)

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

Out-of-network requests — definition & submission rule

DefinitionOut-of-network requests are requests for services provided by out-of-network providers that must be submitted by an in-network provider

ExceptionEmergent or urgent care is excluded from the in-network submission requirement for out-of-network services

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for Texas CHIP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

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

SourceLink

On This Page

Related submission noteSee 'How to submit prior authorization requests' for portal, phone and fax options

Prior Authorization Effective Date — field meaning

Field meaning'Prior Authorization Effective Date' indicates the date the prior authorization requirement became effective for the listed code

Usage exampleEntries in the code lists include this field (examples show Jan. 1, 2021 and other dates) to indicate when the requirement began

Operational impactProviders should check the effective date to determine whether a prior authorization applies to the date of service

Additional Information / How to obtain Prior Authorization — field notes

Field presenceThe 'Additional Information/How to obtain Prior Authorization' field is present for entries but is frequently left blank in this segment

ImplicationWhen blank, providers should follow general submission instructions (portal/phone/fax) or contact the listed phone numbers for guidance

Example noteSome entries include contact details or program references in this field when available; many entries remain empty

Durable medical equipment (DME) — definition & authorization condition

DefinitionDurable medical equipment (DME) refers to listed equipment items for which prior authorization is required when retail purchase or cumulative rental cost exceeds $500

ScopeSome DME entries show Prior Authorization Effective Dates (examples include May 1, 2024 and Jan. 1, 2015)

ExclusionsProsthetics are not classified as DME; orthotics and prosthetics have separate rules

Oncology prior authorization submission

Submission channelFor oncology diagnoses, prior authorization requests should be submitted online using the UnitedHealthcare Provider Portal (UHCprovider.com -> Provider Portal -> Prior Authorization and Notification)

Miscellaneous HCPCS drugsChemotherapy injectable drugs billed under miscellaneous HCPCS codes require prior authorization; call 866-604-3267 for these requests

DocumentationOncology entries include 'Additional Information/How to obtain Prior Authorization' fields (often blank); follow portal guidance for submissions

Genetic and molecular testing prior authorization

Notification requirementGenetic and molecular testing requires prior authorization/notification and the ordering provider must indicate the laboratory and test name

Effective datesExamples show various Prior Authorization Effective Dates (e.g., Dec. 1, 2022; Jan. 1, 2019; Nov. 1, 2020) for genetic test codes

Laboratory involvementThe laboratory conducting the test may be required to notify UnitedHealthcare as part of the authorization/notification process

New-to-market medication review / prior notification

Review at Launch referenceNew-to-market medications are subject to 'Review at Launch' and Optum/OptumRx processes; providers are advised to pre-determine coverage

Prior notification routesSome newly approved or specialty medications require prior authorization through Optum SGP or OptumRx processes as noted in entries

Where to find policy'Review at Launch for New to Market Medications' policy is available at UHCprovider.com under Community Plan Policies

Review at Launch — New-to-market medications

Purpose'Review at Launch' is the payer process for evaluating newly approved (new-to-market) medications and determining prior authorization requirements

Provider recommendationPre-determination (prior authorization) is highly recommended for drugs listed on the Review at Launch Medication List

AccessThe Review at Launch policy and medication list are located on UHCprovider.com > Policies and Protocols > Community Plan Policies

Proton Beam Therapy — term reference

TermProton Beam Therapy — focused radiation therapy using beams of protons

Codes listedExample HCPCS/CPT codes associated: 77520, 77523 (entries include related codes 77522, 77525)

Authorization notePrior authorization entries show Jan. 1, 2015 as an effective date for Proton Beam Therapy entries in this document

Site of Service (SOS) - outpatient hospital

DefinitionSite of Service (SOS) — outpatient hospital: prior authorization is required only when requesting the listed service in an outpatient hospital setting

Scope examplesApplies to a range of procedures across specialties (ENT, cosmetic/reconstructive, digestive, etc.) when performed in an outpatient hospital

Provider actionProviders should confirm site of service when submitting prior authorization as authorization may not be required in other settings

Stimulators / Implantable electrical impulse device

DefinitionStimulators — implantable electrical impulse devices: implantation of a device that sends electrical impulses (e.g., neurostimulation, bone growth stimulators)

Coding examplesEntries include CPT/HCPCS codes and device codes (examples in spinal/stimulator section) with Prior Authorization Effective Dates

Authorization datesSome stimulator implantation entries show Prior Authorization Effective Date = Jan. 1, 2015 or Dec. 7, 2015

Ventricular Assist Device (VAD) — definition & PA effective date

DefinitionVentricular Assist Device (VAD): a mechanical pump that takes over heart function

Authorization instructionPrior authorization effective Jan. 1, 2018; additional instructions reference forms on the member's health plan ID card and faxing to Optum VAD Case Management

Operational noteProviders should follow the specified coordination/notification process for VAD prior authorization as detailed in the document