CurrentUnitedHealthcarePolicy N/A

UnitedHealthcare Prior Authorization / Prescription Drug Request Form (Provider-Payor Communication)

A multi-section prior authorization and clinical information submission form for provider requests to UnitedHealthcare Medical Benefit for prescription drugs (including provider-administered drugs and opioids), capturing prescriber, patient, clinical, and drug-specific data to support coverage decisions.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Prior Authorization / Prescription Drug Request Form (Provider-Payor Communication)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and submit this form to UnitedHealthcare Medical Benefit including prescriber, patient, drug, clinical justification, prior treatments, and attestation statements to request coverage or reauthorization.

POLICY UPDATE CHANGES

No material clinical/coverage changes

7Form Sections

3Identifier Types

1Opioid Attestation Blocks

Policy overview & purpose

This form is a standard UnitedHealthcare Medical Benefit prior authorization form used to collect necessary information from prescribers to evaluate coverage for prescription medications, including outpatient and provider-administered drugs and opioid-specific requirements.

Key Metadata

subjectUnitedHealthcare Prior Authorization / Prescription Drug Request Form (Provider-Payor Communication)

payerUnitedHealthcare

statusCURRENT

scope_summaryA multi-section prior authorization and clinical information submission form for provider requests to UnitedHealthcare Medical Benefit for prescription drugs (including provider-administered drugs and opioids), capturing prescriber, patient, clinical, and drug-specific data to support coverage decisions.

thresholds_summaryCumulative daily MME: Documented numeric field; compared to the plan's daily max MME allowed (yes/no question)

Requested identifiers and billing codes (form fields)

Identifiers and Billing Codes (form fields)mixed

HCPCS/CPT-4	Field for provider-administered drug billing code
NDC	Field for National Drug Code for provider-administered drugs
ICD-10	Field for primary and secondary diagnosis codes

The form requests identifiers for both prescription and provider-administered drugs. For provider-administered drugs it specifically requires HCPCS/CPT-4 and NDC (along with dose per administration and servicing provider/facility name and NPI).

Actions required from providers when submitting the form

Prior Authorization

Submit prior authorization request

Providers must complete and submit this form to UnitedHealthcare Medical Benefit (phone/fax provided) including prescriber, patient, drug, clinical justification, prior treatments, and attestation statements to request coverage or reauthorization of prescription drugs or provider-administered therapies.

Phone: 1-888-397-8129 (as listed on form)
Fax: 1-877-271-6290 (as listed on form)

Documentation Required

Provide clinical and diagnostic information

Include primary and secondary ICD-10 diagnosis codes, dates diagnosed, pertinent lab values with dates, past and current pharmacologic and non-pharmacologic treatments (drug names, dates, response, dose, duration), and allergies.

ICD-10 primary and secondary diagnosis codes
Dates diagnosed for each diagnosis
Pertinent laboratory values with dates
Past and current pharmacologic and non-pharmacologic treatments with drug names, dates, response, dose, and duration
Documented drug allergies

Documentation Required

Opioid-specific attestation and documentation

For opioid requests, document whether quantity exceeds max quantity limit, cumulative daily MME, and attest to assessments (pain/function assessment, substance use screening, PMP checks, treatment plan, opioid treatment agreement when applicable) and prior short-acting opioid trials.

Document cumulative daily MME (numeric) and whether it exceeds the plan's daily max MME
Attest that a pain and function assessment was performed
Attest that the patient was screened for substance use/opioid dependence
Attest that the Prescription Monitoring Program (PMP) will be accessed for controlled prescriptions
Attest that a treatment plan (current and previous goals for pain and function) has been developed
Attest that an Opioid Treatment Agreement is on file when applicable
Document prior short-acting opioid trials (drug(s), dose, duration, dates)

Billing Rule

Provider-administered drug details required

If provider will administer drug, supply HCPCS/CPT-4 code, NDC, dose per administration, and servicing provider/facility name and NPI.

HCPCS/CPT-4 code
NDC number
Dose per administration
Servicing provider/facility name and NPI

Documentation Required

Prescriber signature and attestation

Prescriber must sign and attest to truthfulness of information and to attestation statements applicable to the request.

Who and when this form applies

This is a multi-section prior authorization and clinical information submission form for UnitedHealthcare Medical Benefit covering prescription drugs, provider-administered drugs, and opioids. It captures prescriber details, patient demographics and diagnoses (including ICD-10 codes), prescription drug information (drug name, strength, directions, quantity, days' supply), and provider-administered drug billing identifiers.

The form includes an opioid-specific section requesting whether the quantity requested exceeds the plan limit, cumulative daily MME, and a series of attestation statements (pain/function assessment, substance use screening, PMP checks, treatment plan, opioid treatment agreement, and prior short-acting opioid trials).

This document serves as informational guidance for submission requirements to support coverage decisions and reauthorizations under UnitedHealthcare Medical Benefit.

Thresholds

Cumulative daily MMEDocument a numeric cumulative daily MME value. The form asks whether the cumulative daily MME exceeds the plan's daily max MME allowed (Yes/No) and requests justification if it does.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Prior Authorization / Prescription Drug Request Form (Provider-Payor Communication)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

On This Page

OpenPayer

UnitedHealthcare Prior Authorization / Prescription Drug Request Form (Provider-Payor Communication)

Policy overview & purpose

Document-level changes

Key definitions referenced on the form

Requested identifiers and billing codes (form fields)

Actions required from providers when submitting the form

Who and when this form applies

Revision history