General prior authorization eligibility — Covered when ALL of the following are met
Covered when ALL of the following are met:
ALL of the following
The requested service is a covered benefit under AHCCCS and UnitedHealthcare Community Plan of Arizona Long Term Care.
Prior authorization request is submitted using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by calling the prior authorization phone line as specified in the header.
Clinical documentation demonstrating medical necessity accompanies the prior authorization request and supports the type, frequency, and duration of the requested service.
The rendering provider, facility or vendor is actively registered with AHCCCS.
Only one ordering/requesting health care professional is listed on the prior authorization request form.
Allergy testing and immunotherapy — Coverage depends on member age and clinical severity
Coverage depends on member age and clinical severity:
In‑home nutritional therapy — coverage condition: Covered when documentation and prior authorization are provided
Coverage condition: Prior authorization required and clinical documentation must accompany the request to establish medical necessity for in‑home nutritional therapy.
ALL of the following
In‑home nutritional therapy (enteral via gastrostomy tube, total parenteral nutrition, lipids, and/or oral supplements) requires a completed Certificate of Medical Necessity or equivalent clinical documentation as applicable.
Prior authorization must be obtained before initiation of services, and documentation must justify the route of administration, formulation, caloric goals, and duration of therapy.
For members younger than 21 years, EPSDT rules apply; supporting documentation should reference AMPM Chapter 400, Section 430 (Policy 430-10) when applicable.
Requests for ongoing supplies or replacement equipment should include clinical progress notes and monitoring plans demonstrating continued medical necessity.
Dental services — coverage condition: Covered when prior authorization obtained
Coverage condition: Prior authorization required for dental services listed; clinical documentation must justify care when applicable.
ALL of the following
Prior authorization is required for the listed dental HCPCS/CPT codes (examples: K0837–K0891, S1040 and related codes) before services are provided when indicated in the code list.
Clinical documentation must be provided to establish medical necessity for the requested dental procedure or device (including prosthetic components and supplies) when requested or when required by AHCCCS guidelines.
For enteral/parental services and oral nutritional supplements associated with dental or feeding needs, a Certificate of Medical Necessity must accompany the prior authorization request as applicable (codes include B4034–B4161, B4102–B4149 series as listed).
For members younger than 21 years, reference to EPSDT and AMPM Chapter 400, Section 430 may be required to determine coverage of related services.
Services requiring prior authorization — Covered when prior authorization and referenced clinical documentation requirements are met for the listed codes
Covered when prior authorization and referenced clinical documentation requirements are met for the listed codes:
ALL of the following
Prior authorization is required for the procedures, services and codes identified throughout this code list (examples include but are not limited to bariatric surgery, behavioral health inpatient admissions, hearing device hardware/supplies, cosmetic/reconstructive procedures, genetic testing, and specified surgical procedures).
Requests must include the appropriate CPT/HCPCS code(s) and supporting clinical documentation to demonstrate medical necessity, prior treatments tried, and expected clinical benefit.
Experimental, investigational, or not medically necessary services are not covered; services determined to be experimental/investigational require prior authorization and may be reviewed under separate policy guidance.
Incontinence supplies — Prior authorization criteria: Covered with prior authorization when quantity thresholds are exceeded
Prior authorization criteria: Covered with prior authorization when quantity thresholds are exceeded for incontinence supplies:
ANY of the following
Members younger than 21:
ALL of the following
Prior authorization is required for incontinence briefs and diapers (including pull‑ups) when requests exceed 240 per month.
Members 21 and older:
ALL of the following
Prior authorization is required for incontinence briefs and diapers (including pull‑ups) when requests exceed 180 per month.
Injectable medications — Prior authorization required for administration/coverage of the following medications
Prior authorization required for administration/coverage of the following injectable medications and listed codes:
ALL of the following
Prior authorization is required for administration and coverage of the injectable medications listed below; the J/Q/other HCPCS code for each product must be supplied on the prior authorization request.
The request must include indication, relevant prior therapies, dosing regimen, provider specialty, and any required laboratory or diagnostic documentation to support medical necessity.
New‑to‑market medications may be subject to the Review at Launch for New to Market Medications policy; predetermination is recommended for those products. Unclassified/temporary codes (eg, C9094, J3490, J3590) may require additional clinical detail and are prior‑auth required for specified agents per the policy note.
At least 1 of the following
Inpatient admission criteria — Covered when ALL of the following are met
Covered when ALL of the following are met:
ALL of the following
An inpatient admission meets clinical criteria and is the most appropriate setting for the level of care required (examples listed include behavioral/substance abuse, elective surgery with admission, hospice, long‑term acute care/rehabilitation, skilled nursing facility admissions).
Prior authorization is obtained for non‑emergent inpatient admissions per the code list and policy requirements.
Emergency inpatient admissions are not subject to prior authorization but must be reported/telephoned per notification requirements when the member is admitted.
Observation services — 1 top-level node
Observation services — prior authorization and notification rules:
ALL of the following
Prior authorization is not required for observation status; however, notification is required if the member is admitted for an inpatient stay following observation.
Observation orders must be written by a physician or other authorized individual per hospital bylaws.
Orthotics and prosthetics criteria — 1 top-level node
Orthotics and prosthetics — prior authorization overview:
ALL of the following
Prior authorization is required for orthotics and prosthetic codes listed when purchase or cumulative rental cost exceeds $500 or when specified in the code list.
Documentation must establish medical necessity, the preferred treatment option, and demonstrate that the orthotic/prosthetic is the least costly effective alternative.
For members younger than 21 years, orthotic limitations and EPSDT rules may apply and additional documentation should be provided as indicated.
Injectable medications criteria — 1 top-level node
Injectable medications criteria — top-level requirements:
ALL of the following
All injectable medications listed require prior authorization and supporting clinical documentation as outlined in the injectable medications criteria group above.
Provide product‑specific information: indication, weight/dose calculations, planned administration setting, and monitoring requirements when applicable.
Therapy coverage with PA — Covered when documentation and prior authorization requirements are met
Therapy coverage with PA — Covered when documentation and prior authorization requirements are met:
ALL of the following
Outpatient occupational, physical and speech therapy for members under 21 are covered when medically necessary; prior authorization is required after the initial evaluation and before ongoing therapy visits.
For members 21 and older, prior authorization is required for occupational and speech therapy; outpatient physical therapy prior authorization rules differ and are described in the therapy section.
Orthotics & Prosthetics coverage with PA — Covered when prior authorization and documentation justify device or component need
Orthotics & Prosthetics coverage with PA — Covered when prior authorization and documentation justify device or component need:
ALL of the following
Requests for orthotic or prosthetic devices and components must include clinical justification, functional limitations, and prior conservative treatments tried.
Replacement or repair requests should include the reason for replacement and documentation that repair costs exceed replacement thresholds where applicable.
Pregnancy termination coverage with PA — Covered with prior authorization and required documentation
Pregnancy termination coverage with PA — Prior authorization and documentation requirements:
ALL of the following
Prior authorization is required for the listed pregnancy termination codes; the prior authorization request must include clinical documentation and the certificate of medical necessity for pregnancy termination.
Pharmacy/stage-specific drugs coverage with PA — Prior authorization required
Pharmacy / stage‑specific drugs — prior authorization:
ALL of the following
A list of pharmacy drugs requiring prior authorization is maintained on the UnitedHealthcare provider site (UHCprovider.com/AZcommunityplan) and applies to covered pharmacy benefits.
Specialty, hemophilia factor, and biotech drugs listed in the procedures and services section require prior authorization and may require documentation of diagnosis, prior therapies, and specialty pharmacy dispensing details.