DraftUnitedHealthcarePolicy N/A

Prior authorization form for biologic therapy in Crohn's disease and ulcerative colitis

A beneficiary/prescriber form collecting clinical and administrative information to support prior authorization requests for injectable biologic immunomodulators for adults with Crohn's disease or ulcerative colitis.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for biologic therapy in Crohn's disease and ulcerative colitis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete all form fields including beneficiary, prescriber, drug details, and disease‑specific clinical screening to support prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2disease-specific sections

5screening questions per section

3administrative blocks

Coverage Criteria and Required Documentation

Information collected to support medical necessity

Form indicates the following items must be documented for requests related to Crohn's disease or ulcerative colitis

Core administrative data: Beneficiary identifying information, prescriber NPI, requester contact, drug name/strength/quantity/length of therapy are provided

Required fields appear in beneficiary, prescriber, and drug sections

Diagnosis confirmation: For Crohn's: diagnosis of moderate to severe Crohn's disease must be indicated; For UC: diagnosis of ulcerative colitis must be indicated

Each disease section has a Yes/No checkbox

Concurrent biologic use: Provider must indicate beneficiary is not on another injectable biologic immunomodulator

Single checkbox per disease section

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for biologic therapy in Crohn's disease and ulcerative colitis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete all form fields including beneficiary, prescriber, drug details, and disease‑specific clinical screening to support prior authorization.

SourceLink

On This Page

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.

Provider Actions and Form Completion Requirements

Prior Authorization

Form Completion Required for Prior Authorization

Prior authorization requires completion of the form fields for beneficiary, prescriber, and drug details. Submit a fully completed prior authorization form including all requested administrative and clinical fields to avoid processing delays or denial.

Beneficiary identifying information: last name, first name, member ID, date of birth, and gender.
Prescriber information: prescribing provider NPI and requester contact name and phone number (with ext. if applicable).
Drug details: drug name, strength, quantity per 30 days, and length of therapy (select specified duration or enter other).

Step Therapy

Step Therapy Inquiry Regarding Humira

The form includes step-therapy questions specific to Humira. Answer whether the beneficiary has had a trial and failure of Humira or document a clinical reason why Humira cannot be tried.

Crohn's Disease and Ulcerative Colitis sections each ask: "Has the beneficiary had a trial and failure of Humira or a clinical reason beneficiary cannot try Humira?" — must be answered Yes or No.

Documentation Required

Required Clinical Information for Crohn's/UC Requests

Provide disease-specific clinical information for Crohn's disease and ulcerative colitis requests. Complete each clinical question in the appropriate section to support medical necessity review.

For Crohn's Disease (Adult): confirm diagnosis of moderate to severe Crohn's disease; indicate whether the beneficiary is not on another injectable biologic immunomodulator; confirm screening for latent tuberculosis; confirm Hepatitis B surface antigen and core antibody testing; and document Humira trial/failure or clinical reason not to try Humira.
For Ulcerative Colitis (Adult): confirm diagnosis of ulcerative colitis; indicate whether the beneficiary is not on another injectable biologic immunomodulator; confirm screening for latent tuberculosis; confirm Hepatitis B surface antigen and core antibody testing; and document Humira trial/failure or clinical reason not to try Humira.

Denial Risk

Signature Requirement and Legal Attestation

Prescriber signature is mandatory. The prescriber must sign and date the form and attest to the accuracy and completeness of the information. Falsification, omission, or concealment of material facts may result in civil or criminal liability and may be grounds for denial.

Signature of Prescriber and Date are required on the form.
Attestation: "I certify that the information provided is accurate and complete to the best of my knowledge..."

Screening and Testing Definitions

Latent tuberculosis screening

DefinitionAssessment documented on the form asking whether the beneficiary has been considered and screened for the presence of latent tuberculosis infection prior to biologic therapy.

Where askedItem 3 in both the Crohn's disease and Ulcerative Colitis request sections: 'Has the beneficiary been considered and screened for the presence of latent tuberculosis (infection)?'

Response optionsDiscrete Yes/No checkbox per disease section to confirm screening was completed.

Related requirementPart of the disease-specific clinical information required on the prior authorization form for injectable biologic immunomodulators.

Hep B SAG and Core Ab testing

DefinitionDocumentation that Hepatitis B surface antigen (Hep B SAG) and core antibody (Core Ab) testing have been performed prior to initiating biologic immunomodulator therapy.

Where askedItem 4 in both the Crohn's disease and Ulcerative Colitis request sections: 'Has the beneficiary been tested with Hep B SAG and Core Ab?'

Response optionsDiscrete Yes/No checkbox per disease section to confirm testing was completed.

Related requirementIncluded among infectious disease screening items required on the prior authorization form for biologic therapy requests.

OpenPayer

Prior authorization form for biologic therapy in Crohn's disease and ulcerative colitis

Coverage Criteria and Required Documentation

Provider Actions and Form Completion Requirements

Screening and Testing Definitions

Policy Background and Scope