CurrentUnitedHealthcarePolicy PCA-1-24-02692-Clinical-QRG09262024

Prior authorization requirements for Texas CHIP (UnitedHealthcare Community Plan)

Lists services, codes, and instructions for submitting prior authorization requests for UnitedHealthcare Community Plan Texas CHIP providers for inpatient and outpatient services. Applies to participating providers in Texas.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Texas CHIP (UnitedHealthcare Community Plan)

Policy CodePolicy PCA-1-24-02692-Clinical-QRG09262024

Change TypeNo material changes

Effective DateJuly 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, chat 24/7, or fax to 877-940-1972.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-07-01policy effective date shown on document

Online/Chat/Faxsubmission methods listed

No PA requiredemergency/urgent care exception

$500DME cost threshold

Texas CHIPstate program applicability

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Coverage and Medical Necessity Criteria

Coverage criteria not specified in this section.

Prior authorization is required for many services listed below. Emergency or urgent care does not require prior authorization. Out-of-network requests must be made by a network care provider. Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, chat (24/7), or fax to 877-940-1972. The prior authorization request form is available on the UnitedHealthcare provider website.

ANY of the following

Coverage criteria not specified in this section.
This section lists codes and categories that may require prior authorization but does not provide detailed medical necessity criteria within this extract.
Prior authorization is not required for emergency or urgent care services.
Operational exception: submit retrospective notifications as required by program rules.
Prior authorization requests should be submitted by a network care provider for out-of-network services.
See portal, chat, or fax options above for submission methods.

CPT / HCPCS / J / L / Genetic Codes

Submission, Documentation, and Authorization Actions

Prior Authorization

Prior authorization required — submit via Portal, chat, or fax

Prior authorization is required for the CPT and HCPCS procedure codes listed in this policy for Texas CHIP members. Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, via chat 24/7, or by fax to 877-940-1972.

Examples of listed procedure codes include: 43644, 43645, 43659, 43770, 43775, 43845, 43847, 43848, 43860, 20975, 20979, 11971.

Prior Authorization

HCPCS / J‑codes require prior authorization (effective dates noted)

Certain HCPCS and J‑codes require prior authorization; some entries in the injectable/ specialty medication tables show prior authorization effective dates and oncology-specific notes.

Examples include J9390, J9360, J9400, J9600 and oncology-related entries J3590/C9399 with a Jan 1, 2015 effective date.

Policy Background and Scope

Background: this section of the policy enumerates procedure and DME codes associated with services intended to improve or restore physiologic function or treat medical conditions. It provides operational guidance for prior authorization — including code lists, occasional effective dates, and administrative notes (for example, DME cost thresholds and prosthetics classification) — but in the provided excerpt does not contain detailed clinical coverage criteria tied to each code.

Key Definitions and Thresholds

Subcategory / intent

IntentImprove or restore physiologic function (subcategory/intent).

ContextUsed to group reconstructive/procedural CPT codes that aim to restore physiologic function (e.g., 21182, 21184, 21230, 21256).

Location in policyAppears in the Reconstructive / Cosmetic CPT codes section as the stated subcategory intent.

Prosthetics vs DME

DefinitionProsthetics are not classified as DME for the purposes of the DME prior authorization threshold.

ImplicationProsthetic items are excluded from the $500 DME PA cost threshold; see Orthotics and prosthetics guidance for details.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Texas CHIP (UnitedHealthcare Community Plan)

Policy CodePolicy PCA-1-24-02692-Clinical-QRG09262024

Change TypeNo material changes

Effective DateJuly 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, chat 24/7, or fax to 877-940-1972.

SourceLink

On This Page

Prior Authorization

Circumcision (54150, 54160) — prior authorization required for older members

Prior authorization is required for circumcision CPT codes 54150 and 54160 for members older than the specified age; the entry references an effective date of Jan 1, 2015.

Additional information field states: 'Prior authorization required for members older than age.'

Prior Authorization

Cochlear implant codes (69729, 69730, L‑codes) — PA effective Mar 1, 2023

Cochlear implant procedure and device codes (e.g., 69729, 69730 and related L‑codes) require prior authorization; the cochlear implant entries show a prior authorization effective date of March 1, 2023.

Codes shown include 69729 and 69730; device HCPCS examples include L8614, L8619, L8690, L8691.

Prior Authorization

Continuous glucose monitor (A9277) — PA effective Oct 1, 2021

Continuous glucose monitor and related supply codes require prior authorization; A9277 specifically shows a prior authorization effective date of Oct 1, 2021.

Glucose monitor HCPCS listed include E2102, A9276, and A9277.

Prior Authorization

Glucose monitor devices (E2102, A9276, A9277) — PA required

Continuous glucose monitor and glucose monitor HCPCS codes (E2102, A9276, A9277) are included in the prior authorization list; A9277 has an explicit PA effective date of Oct. 1, 2021.

Entries list E2102 and A9276 in the Continuous Glucose Monitor/Glucose Monitor subcategories.

Prior Authorization

Reconstructive / cosmetic CPT codes — PA required; conditional notes present

Multiple reconstructive and cosmetic CPT codes require prior authorization; some reconstructive entries include explicit effective dates and notes such as 'will NOT require prior auth when' or 'billed with skin cancer diagnoses.'

Examples of reconstructive/cosmetic CPT codes listed: 14020, 14041, 14061, 15820–15823, 17106–17108, 17999, 21138–21184, 21230, 21256.

Prior Authorization

Procedure codes in Texas CHIP table require prior authorization

Procedure codes listed in the Texas CHIP prior authorization tables (including the CPT entries shown throughout the document) require prior authorization before services are provided.

Examples repeatedly listed: CPT 21182, 21184, 21230, 21256.

Prior Authorization

Prior authorization — CPT 21182, 21184, 21230, 21256

The CPT codes 21182, 21184, 21230 and 21256 are enumerated under the Texas CHIP prior authorization heading and require prior authorization; the tables list these codes repeatedly.

These codes are presented under the 'improve or restore physiologic function' subcategory.

Prior Authorization

Prior authorization required — listed procedure and DME codes (DME cost threshold applies)

Prior authorization is required for the procedure and numerous DME HCPCS codes listed for Texas CHIP; the DME section notes that prior authorization is required only when retail purchase or cumulative rental cost exceeds $500 for the listed DME.

Sample DME codes listed include E2298, E0329, E0471, E1130, E2310, E2512.

Denial Risk

Denial risk — DME/ rental items cost threshold > $500

Failure to obtain prior authorization for listed DME or rental items when retail purchase or cumulative rental cost exceeds $500 may result in claim denial; check cost thresholds and obtain PA before service.

The DME section cautions that prior authorization is required only when retail purchase or cumulative rental cost is more than $500 and warns of possible denial without PA.

Prior Authorization

Prior authorization required — selected procedures (experimental, FAI, FESS, etc.)

Selected CPT procedure groups and individual CPT codes listed (e.g., experimental service 33477, FAI and FESS codes) require prior authorization as shown in the tables.

Examples include experimental/linked code 33477; FAI codes A9274, 29914, 29916; FESS codes 31253–31259.

Prior Authorization

Procedure and DME codes — obtain prior authorization before service

Various procedure and DME codes enumerated in the document are subject to prior authorization for Texas CHIP; providers must obtain authorization prior to performing services unless an emergency or urgent care exception applies.

The policy repeatedly lists procedure and DME codes subject to PA throughout the Texas CHIP tables.

Prior Authorization

Genetic & molecular testing — outpatient prior authorization required

Extensive lists of genetic and molecular testing codes require prior authorization when performed in an outpatient setting; the genetic testing section has an effective date of July 1, 2025 and explicitly states outpatient PA is required.

Examples include genetic testing codes 81228, 81277, 81412, 81414, PLA codes and numerous U‑codes.

Prior Authorization

Injectable and specialty medications (J/Q codes) — PA required; obtain before service

Numerous injectable and specialty medication J‑codes and Q‑codes are listed and require prior authorization; providers are advised to obtain authorization prior to service and to follow oncology-specific submission instructions when applicable.

Examples include many J‑codes/Q‑codes across injectable medication entries (see policy tables).

Prior Authorization

PA required — listed injectable medication codes and joint replacement CPTs

Prior authorization is required for the injectable medication HCPCS/CPT codes listed and for the joint replacement CPT codes shown in the injectable/medication section for Texas CHIP members.

Sample injectable codes listed in this segment include J3241, J2357, J1745; joint replacement CPT examples include 23470–23473.

Prior Authorization

Orthotics & prosthetics HCPCS codes — prior authorization required

Prior authorization is required for orthotics and prosthetics HCPCS codes listed (examples include L3763, L4631, L5647, L5649, L5673, L5683, L5700, L5845); some entries note a prior authorization effective date of April 1, 2019.

Providers should follow the orthotics & prosthetics guidance in the table before obtaining items.

Prior Authorization

L‑codes (orthotics/prosthetics) — PA required; cost/rental notes present

Multiple orthotic/prosthetic L‑codes require prior authorization for Texas CHIP; some entries reference effective dates and note special instructions such as retail purchase or rental-cost thresholds.

Examples of L‑codes listed: L5673, L5700, L5845, L5649, L5683, L5705, L5962, L5986, L5999.

Prior Authorization

Orthotics/prosthetics L‑codes listed — PA required (fields shown but often blank)

The prior authorization tables list orthotics and prosthetics HCPCS codes such as L5845, L5986, L5962 and L5999 as subject to prior authorization for Texas CHIP; the tables include fields for diagnosis code and PA effective date though many are blank in this excerpt.

Entry example: L5845, L5986 paired with L5962, L5999 in the orthotics and prosthetics sections.

Prior Authorization

Orthotics & prosthetics (L5845, L5986, L5962) — PA required; check table for details

Prior authorization is required for orthotics and prosthetics items listed (codes include L5845, L5986, L5962) under Texas CHIP; additional authorization details (how to obtain PA) are referenced in the table but not provided in this excerpt.

Providers should check the Additional information/how to obtain prior authorization fields for each code where available.

Documentation Required

Injectable/oncology prior auth notes — submit oncology requests via Portal or 888‑397‑8129

Some injectable medications and oncology‑related J‑ and Q‑codes require prior authorization and oncology diagnosis submissions must be made through the Provider Portal (or by calling the oncology number) as specified; failure to submit via the required channels may affect authorization processing.

Oncology submission instruction: submit online via the UnitedHealthcare Provider Portal or call 888‑397‑8129 for oncology prior auth requests.

Documentation Required

How to submit prior authorization (Portal, chat, fax)

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit requests, or connect via chat 24/7, or fax prior authorization requests to 877‑940‑1972; the prior authorization request form is available on the Provider Portal.

Portal: UHCprovider.com → Sign in with One Healthcare ID → Prior Authorization and Notification tab.
Fax: 877‑940‑1972; Prior Authorization Forms available at UHCprovider.com/TXcommunityplan Prior Authorization and Notification Resources.

Documentation Required

Oncology prior authorization — submit via Provider Portal or call 888‑397‑8129

For oncology diagnoses, submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com → Provider Portal → Prior Authorization and Notification) or call 888‑397‑8129 as described in the oncology entries.

Oncology-specific instruction is repeated in multiple injectable/oncology entries.

Documentation Required

Check per‑code 'Additional information/how to obtain prior authorization' fields

Many table entries include 'Additional information/how to obtain prior authorization' fields; providers should review those fields for code‑specific submission guidance—even though many are blank in this extract.

The document shows per‑code fields for Diagnosis code, Prior authorization effective date, and Additional information/how to obtain prior authorization.

Billing Rule

Orthotics/prosthetics PA — retail purchase or cumulative rental cost > $500 triggers PA

The policy explicitly states prior authorization is required for listed orthotics and prosthetics when the retail purchase or cumulative rental cost exceeds $500; providers should obtain PA when that cost threshold is met to avoid denial.

Policy text: 'Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.'
Orthotics/prosthetics entries note 'rental cost of more than $500.'

Denial Risk

Submission expectation — use Portal/chat/fax or risk lack of prior approval

Failure to submit prior authorization using the Provider Portal, chat, or fax may result in services being performed without prior approval; emergency or urgent care remains exempt from prior authorization requirements.

The cover page instructs providers to submit requests via Portal, chat, or fax and notes emergency/urgent care does not require PA.

Policy text: 'Prosthetics are not DME see Orthotics and prosthetics.'

DME cost threshold

ThresholdPrior authorization is required when retail purchase or cumulative rental cost exceeds $500 for the listed DME codes.

Applies toDME HCPCS codes enumerated in the Durable medical equipment (DME) section (e.g., E2298 and others).

Policy wording'Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.'

DME prior authorization threshold

TriggerRetail purchase or cumulative rental cost greater than $500 triggers prior authorization for listed DME codes.

ScopeOnly applies to the specific DME codes listed in the table; prosthetics are not included under this threshold.

ActionObtain PA before billing/purchase when cumulative purchase/rental exceeds $500 to avoid denial.

Genetic and Molecular Testing (outpatient)

RequirementGenetic and molecular testing performed in an outpatient setting requires prior authorization.

Effective date noteGenetic/molecular testing entries show a prior authorization effective date of July 1, 2025 for the group in the table.

Submission guidanceSubmit PA for outpatient genetic/molecular tests via the Provider Portal as indicated elsewhere in the policy.

Gender Dysphoria Treatment

RequirementPrior authorization is required for the listed gender dysphoria treatment procedure codes regardless of diagnosis (any DX).

Codes exampleGender dysphoria and treatment codes listed include 31240, 31255, 31267, 31287, 55970 and related procedure codes.

Effective dateSome gender dysphoria treatment entries show effective dates (e.g., July 1, 2018) for specific groups in the policy.

Orthotics and prosthetics prior authorization

RequirementPrior authorization is required for orthotics and prosthetics items listed in the policy.

Cost/rental thresholdsPA applies when retail purchase or cumulative cost exceeds $500 and when rental cost is more than $500 for listed items.

Effective datesSome L‑code groups show a PA effective date of April 1, 2019 for several prosthetic/orthotic entries.