CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Hawaii Medicaid

Lists services, CPT/HCPCS/ICD codes, and instructions for prior authorization for UnitedHealthcare Community Plan in Hawaii participating providers; applies to inpatient and outpatient services and excludes emergency/urgent care.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Hawaii Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2024

Next Review Date

Key ActionObtain prior authorization before providing listed non-emergent services and submit requests via the Provider Portal, phone, or fax as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-04-01policy effective date

Portal/Phone/Faxsubmission methods

Many servicesprior auth required

$500O&P cost threshold

PA requiredenteral services

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Authorization-required coverage

Covered when prior authorization is obtained for the listed services and codes

PA required: Prior authorization requested and approved for the specific listed injectable medications, inpatient services, joint replacement procedures, non-emergent air ambulance transport, off-island travel, orthotics and prosthetics exceeding cost threshold

Providers must follow submission instructions: fax inpatient registration/admission documents to UnitedHealthcare Community Plan of Hawaii at 800-267-8328; request off-island travel authorization online or by phone using instructions at the top of page 1. For emergency admissions, notify UnitedHealthcare within 48 hours. Orthotics/prosthetics require prior authorization when retail purchase or cumulative rental cost is more than $500.

Emergency or urgent care services do not require prior authorization. Providers should still follow notification procedures for emergency admissions where specified, but authorization for emergent or urgent care is not required per the plan.

Prior authorization is not required for EEG services performed in an outpatient hospital or ambulatory surgical center setting. The policy notes that prior authorization is required for inpatient cerebral seizure monitoring/video EEG, but outpatient hospital or ambulatory surgical center EEGs do not require prior authorization.

The document indicates that prior authorization is not required when the listed CPT/HCPCS services are billed with the specified diagnosis codes. (Text appears as: “*Prior authorization not required when billed with the following” followed by the diagnosis code list.)

Incontinence supplies are covered only when provided through the contracted vendor. Incontinence supplies are a benefit only when provided through Medline; requests for supplies should be directed to Medline at 877-816-5587 as noted in the policy.

For members residing in a skilled nursing facility, prior authorization is not required for the services listed in the home/community-based section; the policy states prior authorization is required in outpatient settings but explicitly notes it is not required for members in a skilled nursing facility.

This fragment does not list any explicit coverage exclusions beyond items managed by other programs; it focuses on DME and PA rules. No specific services are declared excluded in the cited chunks.

These chunks contain repeated code placeholders and PA references but do not provide explicit coverage criteria or stated exclusions. Many entries here are placeholders without substantive coverage language.

This fragment largely contains repeated placeholders for CPT/HCPCS codes and prior authorization references and therefore does not present explicit coverage criteria or exclusions; entries are incomplete in the source text.

This section includes placeholders for CPT/HCPCS codes and prior authorization notes but does not provide full coverage criteria in the fragment. It signals that some codes are present and that prior authorization may not be required when billed with listed diagnosis codes, but the chunk itself contains limited actionable criteria.

Routine obstetric admissions and deliveries require notification only rather than full prior authorization. The policy states inpatient services require prior authorization, and for emergency admissions providers must notify within 48 hours, while routine OB and deliveries require notification only per the inpatient services guidance.

Prior authorization is required for the orthotics and prosthetic HCPCS L‑codes listed when the retail purchase or cumulative rental cost exceeds $500. Documentation to support the prior authorization must demonstrate the retail purchase or cumulative rental cost when requesting authorization.

Organ transplant services are managed outside the plan under the State of Hawaii program. Specifically, organ transplants are a carve‑out benefit under the State of Hawaii Organ and Tissue Transplant (SHOTT) program and are not covered by the Hawaii Medicaid QUEST Integration health plan; providers must contact the UnitedHealthcare Community and State Transplant Case Management team for routing.

No statements in these chunks explicitly label services as "not medically necessary." The fragment lists HCPCS/J‑codes and drug names associated with prior authorization but does not include explicit non‑coverage (not medically necessary) determinations in the cited text.

Within these chunks there are no explicit declarations that services are not medically necessary. The text repeats code placeholders and prior authorization references but does not include 'not medically necessary' language.

What Providers Must Do

Prior Authorization

Prior Authorization Required for Listed Codes

Prior authorization is required for the CPT, HCPCS and J/HCPCS drug codes listed in this policy before billing. Failure to obtain prior authorization for the services and codes listed (excluding emergency or urgent care) may result in denial of payment.

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-980-8728.
Prior authorization is required only for the specific DME/L and other codes listed and for orthotics/prosthetics when the retail purchase or cumulative rental cost exceeds $500.
Prior authorization is not required for emergency or urgent care.

Prior Authorization

Medical Device and Implant Prior Authorization

Providers must obtain prior authorization for medical devices and implants identified in the listing, including cochlear and other auditory implants, continuous glucose monitors and related supplies, and certain implanted stimulators and device codes.

Cochlear and auditory implant codes include: 69710, 69714, 69930, L8614, L8619, L8690, L8691, L8692.
Continuous glucose monitor & supply codes include: A4226, A4239, A9276, A9277, A9278.
Implanted device and stimulator codes (examples) include L8680–L8688 range and procedure codes such as 61863–61886, 63650, 63655, 63685, 64553, 64555, 64568, 64570.

Prior Authorization

Genetic and Molecular Testing Prior Authorization/Notification

Prior authorization or notification is required for genetic and molecular testing codes enumerated in this policy. When requesting authorization for molecular/genetic tests, include the test name and the laboratory performing the test.

Examples of CPT codes requiring prior authorization/notification include: 81162–81164, 81228–81229, 81277, 81349, 81400–81412, 81415–81417, 81420, 81431–81438, 81440, 81443, 81445, 81448, 81460, 81465.
Molecular test codes (examples) include: 81507–81523, 81546, 81595, 81599, 87505–87507.
Many U‑codes and other proprietary codes (e.g., 0006M, 0007M, 0018U, 0022U, 0023U, 0026U, 0060U, 0087U, 0088U, 0111U, 0129U, 0154U, 0170U–0173U, 0175U, 0179U, 0209U, 0214U, 0252U–0300U, 0537T–0540T) also require authorization/notification. Include test name and lab on the request.

Note

Cerebral Seizure Monitoring / EEG Prior Authorization Note

EEG/cerebral seizure monitoring has distinct inpatient vs outpatient rules: prior authorization is required for inpatient video cerebral seizure monitoring/video‑EEG services; outpatient hospital or ambulatory surgical center video EEG services are addressed elsewhere and may not require prior authorization.

Inpatient video EEG codes: 95700, 95711, 95712 — prior authorization required.
Outpatient video EEG performed in an outpatient hospital or ASC may not require prior authorization; check the outpatient code listings and diagnosis linkage noted in the policy.
For inpatient admissions, notify or request authorization per inpatient PA instructions (see inpatient PA request method).

Prior Authorization

Inpatient PA Request Method and Off‑Island Travel Submission

To request prior authorization for inpatient services, fax the member's registration/admission document with pertinent information (including date of service or date of admission) to UnitedHealthcare Community Plan of Hawaii at 800-267-8328. For off‑island (including out‑of‑state) travel prior authorization, submit online or by phone using the instructions at the top of page 1.

Inpatient PA fax: 800-267-8328 — include registration/admission and date(s).
Off‑island travel PA: request online via the Provider Portal or call 888-980-8728 as instructed on page 1.
For emergency admissions, notify UnitedHealthcare within 48 hours of admission per inpatient rules.

Prior Authorization

Transplant and CAR T‑cell Therapy Prior Authorization Contact

Prior authorization is required for select transplant and CAR T‑cell therapies. These services may have special routing or carve‑out requirements; contact the UnitedHealthcare Community and State Transplant Case Management team for prior authorization and coordination.

For transplant and CAR T‑cell therapies (examples: Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta), call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card.
Organ transplants are a carve‑out under the State of Hawaii SHOTT program and are not covered by the plan; UnitedHealthcare Community Plan of Hawaii manages referrals to SHOTT.
Some gene and cell therapies (e.g., Casgevy, Skysona, Lantidra, Lyfgenia, Zynteglo) require prior authorization through Optum Transplant — follow the special routing noted in the policy.

Note

Operational Notes, Step Therapy, Private Duty Nursing and Wound VAC

Operational and other provider actions to note: some services require prior authorization only in specific settings, some require notification only, and no step‑therapy or multi‑step sequencing is specified in this listing. Private duty nursing and wound VAC therapies also require prior authorization as indicated below.

No explicit step therapy requirements or sequence are specified within this compiled list — follow individual drug or program policies where applicable.
Private duty nursing (T1000, T1002, T1003) — prior authorization only required.
Wound VAC (E2402) — prior authorization required.

Terminology and Acronyms

Definition — Prior authorization process

DefinitionPrior authorization is the process by which providers submit requests to UnitedHealthcare Community Plan to obtain approval before providing non-emergent services.

Submission methodsRequests can be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 888-980-8728.

ScopeApplies to non-emergent inpatient and outpatient services listed in this policy.

Definition — auditory implants

TermAuditory implants: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve improved hearing.

ExamplesIncludes cochlear implant CPT/HCPCS codes such as 69710, 69714, 69930 and HCPCS L8614, L8619, L8690-L8692.

PA noteAuditory implant devices are listed as 'Prior authorization required.'

Definition — auditory implants (alternate fragment)

Alternate wordingAuditory implants: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve auditory function.

ContextUsed in policy text to describe cochlear and related implants that require prior authorization.

Associated codesSee cochlear and auditory implant CPT/HCPCS codes in coding tables for PA requirements.

Definition — Genetic and molecular testing (including BRCA)

DefinitionGenetic and molecular testing: includes molecular and genetic tests such as BRCA gene testing that require prior authorization or notification as listed.

ExamplesPolicy references CPT/HCPCS codes in ranges (e.g., 81162-81465, 81416, 81420, many U- and M-codes and specific U-codes like 0006M, 0022U).

Provider actionWhen requesting authorization for molecular/genetic tests, include test name and laboratory performing the test as required information.

Definition — HCPCS/J‑code drug listing (partial)

DescriptionHCPCS/J‑code drug listing: partial list of injectable medications and associated J-codes referenced in the policy (examples include J1290, J2840, J2507, J0217, J1932, J0202, J0174, J1306, J2778, J0221).

UseThese HCPCS/J‑codes are present in the prior authorization listing and are associated with specific drug/brand names in the document.

Provider actionRefer to the full coding tables in the policy for specific PA requirements for each HCPCS/J-code.

Definition — Lumizyme (J0221)

CodeLumizyme — J0221.

ContextLumizyme (J0221) is repeatedly listed and associated with prior authorization requirements in the document.

Provider actionDocumentation must reference J0221 when requesting authorization for Lumizyme as indicated in the policy.

Definition — J2778

CodeJ2778 — referenced alongside Lumizyme and other HCPCS entries.

ContextAppears in the HCPCS coding fragments that reference prior authorization requirements.

Provider actionCheck associated documentation and PA instructions when submitting requests for J2778-coded services.

Definition — Brand names Actemra, Luxturna, Lumizyme referenced

Brands referencedBrand names Actemra, Luxturna, Lumizyme are mentioned in the policy alongside HCPCS/J‑codes.

ContextBrand names appear in multiple HCPCS/J-code fragments and are linked to PA listings.

Provider actionWhen requesting prior authorization, include both the HCPCS/J-code and brand name as applicable in documentation.

Definition — SHOTT (State of Hawaii Organ and Tissue Transplant program) carve-out

SHOTTState of Hawaii Organ and Tissue Transplant (SHOTT) program; organ transplants are a carve-out benefit managed through SHOTT and not covered by the Hawaii Medicaid QUEST Integration plan.

Provider actionFor transplant services, contact the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or follow SHOTT routing as specified.

ScopeTransplant services require coordination via SHOTT; do not follow standard PA routing in this policy for carved-out transplants.

Definition — Optum Transplant designated prior authorization routing for select cellular and gene therapies

Optum Transplant routingSelected gene and cell therapies (e.g., Casgevy, Skysona, Lantidra, Lyfgenia, Zynteglo) require prior authorization through Optum Transplant.

Provider actionFollow Optum Transplant PA routing instructions for listed cellular and gene therapies rather than the standard PA pathway.

ContactRefer to the policy entries directing providers to Optum Transplant for select therapies and to the Transplant Case Management contact as applicable.

OpenPayer

Prior authorization requirements for Hawaii Medicaid

Services Requiring Authorization and Exceptions

CPT, HCPCS, and ICD-10 Codes

What Providers Must Do

Policy Scope and Purpose

Terminology and Acronyms