CurrentUnitedHealthcarePolicy PCA-1-22-00194-Clinical-WEB_02282022

Prior authorization requirements for Florida Medicaid

Lists inpatient and outpatient services that require prior authorization for providers participating with UnitedHealthcare Community Plan in Florida and explains how to request authorization.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Florida Medicaid

Policy CodePolicy PCA-1-22-00194-Clinical-WEB_02282022

Change TypeNo material change

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-07-01policy effective date

Phone & onlinerequest methods

Manycodes referenced

Prior auth requirednotable requirements

Outpatient onlyhome health

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transplant/CAR T-cell

Coverage Criteria and Scope

General prior authorization requirement

Covered when prior authorization is obtained for listed services:

General requirement: Providers participating with UnitedHealthcare Community Plan in Florida must submit prior authorization requests for the inpatient and outpatient services listed in this document via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tile) or by phone (877-842-3210), except for emergency or urgent care.

Failure to obtain prior authorization for listed inpatient or outpatient services may result in denial; emergency or urgent care are exceptions.

Cerebral seizure monitoring - inpatient video EEG

EEG authorization specifics:

Inpatient video EEG: Prior authorization is required for inpatient cerebral seizure monitoring — inpatient video electroencephalogram (EEG) (examples: diagnosis code 173.81 and CPT codes 95700, 95714, 95720, 95711, 95715, 95722, 95712, 95716, 95724, 95726).

Outpatient hospital or ambulatory surgical center EEG services do not require prior authorization per this section.

Emergency and urgent care services are exempt from the prior authorization requirement. Providers should submit prior authorization requests for the other inpatient and outpatient services listed in this policy via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-842-3210. Failure to obtain authorization for listed non-emergent services may result in claim denial.

Prior authorization is not required for chemotherapy administered in an outpatient hospital or ambulatory surgical center setting. However, inpatient chemotherapy and other listed inpatient services (for example, inpatient video EEG) do require prior authorization as noted elsewhere in this policy.

The policy clarifies that prosthetics are not considered durable medical equipment (DME). Prosthetic items are addressed separately from DME codes when determining whether prior authorization is required.

Within the excerpt provided there are no additional standalone coverage exclusions described; the document primarily enumerates medications, CPT/HCPCS codes and service categories that require prior authorization rather than listing broad exclusionary conditions.

No explicit coverage exclusions (medical necessity denials) are stated in these chunks. The text instead repeats prior authorization references for specific drug codes (for example, Xembify J1558) and explains that certain unclassified or temporary codes require authorization only when used for specified drugs.

Prior authorization is required for certain unclassified and temporary codes only when they are used to bill for specific drugs. Examples include C9090, C9094, C9151, C9166, C9167, C9168, C9399, J3490 and J3590, which require authorization for named products listed in the policy.

Some services and codes billed for Place of Service Home (Place of Service 12) are explicitly noted as not requiring prior authorization in this policy excerpt. Providers should check the specific code lines, but home-based place-of-service claims identified as exempt can be processed without prior authorization.

The policy reiterates that prior authorization is not required for certain services when billed with Place of Service Home / 12. Where that exception applies, providers may bill the home setting without obtaining prior authorization for the listed codes.

Code 38232 has a limited prior authorization requirement: it will only require prior authorization when submitted with an oncology diagnosis. Submissions for 38232 with non-oncology diagnoses are not subject to the oncology-specific PA requirement described here.

No conditions or services are explicitly listed as "not medically necessary" within the provided chunks. The document functions primarily as an administrative prior authorization list rather than a medical necessity policy.

Codes and Code Lists Requiring Prior Authorization

Covered HCPCS/J-codes (Injectable medications requiring prior authorization)HCPCSCovered

J1555	Immune globulin (human), non-lyophilized (e.g., liquid), 500 mg
J1561	Immune globulin (human), 10% solution, 1 g
J1572	Immune globulin (human), 5% solution, 500 mg
Jxxxx	Placeholder for referenced J-code (ensure specific J-code populated in authoritative source)

Provider Actions, Submission Instructions, and Denial Risks

Prior Authorization

Provider Action — Prior Authorization Required

Prior authorization is required for many services, medications, devices and CPT/HCPCS/J‑codes listed below. Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com > Sign In > Prior Authorization and Notification) or by the phone numbers listed for specific service types. Failure to obtain required prior authorization may result in claim denial; emergency and urgent care services are excluded. Some items may require prior notification to other vendors (for example, OptumRx). Requests must include the relevant CPT/HCPCS/J‑codes and clinical documentation; some requests must be submitted by the member’s primary care provider as noted.

Portal submission: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).
Phone submission: General PA phone line 877-842-3210 (see service-specific contact numbers for advanced imaging, outpatient therapy, transplant/CAR T-cell, OptumRx prior notification, VAD case management).
Submission origin requirement: Certain requests (for example outpatient therapy evaluation/re-evaluation codes) must be submitted by a primary care provider.
Coding required on prior auth requests: Providers must reference the specific CPT/HCPCS/J codes (including J‑codes and HCPCS drug codes) when requesting prior authorization for injectable medications, DME, O&P, and other listed services.
Denial risk for missing prior authorization: Claims for services that require PA and are performed without prior authorization may be denied; where no explicit denial triggers are present, PA is still required when noted and lack of PA can affect payment determination.

Background and Policy Scope

This document is an administrative prior authorization list. It does not provide detailed clinical criteria for medical necessity decisions; instead it enumerates service categories, CPT/HCPCS and ICD-10 codes that require prior authorization and provides instructions for how providers should request authorization (online via the Provider Portal or by phone).

Key Definitions

Prior authorization — definition

DefinitionPrior authorization: A requirement that providers obtain approval from UnitedHealthcare before delivering certain inpatient or outpatient services listed in this policy.

How to requestSubmit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone at 877-842-3210.

ExceptionEmergency or urgent care services do not require prior authorization.

Cochlear implants and other auditory implants — definition / device description

Device descriptionCochlear implants and other auditory implants: a medical device implanted within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational hearing.

Authorization note

Policy Revision History

2024-07-01policy_effectiveLatest

Policy became effective July 1, 2024

2022-02-28policy_publication

Policy published as PCA-1-22-00194-Clinical-WEB_02282022

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Florida Medicaid

Policy CodePolicy PCA-1-22-00194-Clinical-WEB_02282022

Change TypeNo material change

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-842-3210.

SourceLink

On This Page

Prior Authorization

Tezspire Prior Authorization Codes

Tezspire is listed and requires prior authorization when billed with its J‑code(s). Include the J‑code on the prior authorization request.

Tezspire J2356 and (alternate/associated) J3241 references appear in the listing — ensure the exact J‑code used on the claim is included on the PA request.
If the drug appears on a Review at Launch / New‑to‑Market list, pre‑determination is recommended per Review at Launch guidance.

Prior Authorization

Prior Authorization — Injectable Medications and Drug HCPCS

Many injectable medications (J‑codes) and specialty drug HCPCS codes require prior authorization. When requesting PA, include the drug name and the exact J‑ or HCPCS code(s). Some high‑cost/novel drugs are included on Review at Launch and may need pre‑determination or OptumRx notification.

Examples include (non‑exhaustive): J0256, J9202, J0218, J3399, J2357, J1558, J0178, J0179, J2777, J1439, J1437, J1411, J2350 and many others listed in the injectable medications sections.
Drug HCPCS prior authorization examples and specialty codes (C‑codes and unclassified/temporary codes such as C9090, C9166, C9167, C9168, C9399, J3490/J3590) may require PA for specific products.
Prior notification requirement: Cimzia, Synagis and Xolair require prior notification through OptumRx Prior Notification Services at 800-310-6826; follow OptumRx instructions when noted.

Prior Authorization

Provider Action — Named Medications

Named medications and examples are included in the drug lists; include the drug name and code on the PA request and follow Review at Launch guidance for new drugs.

Examples shown in the list: Zemaira (J0256), Zoladex (J9202), Zolgensma (J3399), Xembify (J1558), Xenpozyme (J0218), Xolair and many others.
Pre‑determination strongly recommended for drugs on the Review at Launch for New to Market Medications list.

Prior Authorization

Procedures and Services Requiring Prior Authorization

Procedures and services across many specialties require prior authorization. Verify the CPT/HCPCS codes and place of service rules before scheduling; some services are prior authorization only in certain settings or only when associated with specific diagnoses.

Examples include joint replacement (total hip/knee), spinal surgery, sleep apnea surgical procedures, rhinoplasty/septoplasty for functional impairment, carpal tunnel, many ENT (sinuplasty, endoscopic sinus) and ophthalmologic procedures.
Advanced outpatient imaging (certain CT/MRI/MRA/PET/nuclear studies) requires notification and PA — see the advanced imaging submission instructions and call 866‑889‑8054 or use the portal.
Oncology‑specific PA requirement: Code 38232 requires prior authorization only when billed for an oncology diagnosis.

Prior Authorization

Orthotics & Prosthetics — Codes and Cost Threshold

Orthotics & Prosthetics (O&P) and many HCPCS L‑codes require prior authorization when the retail purchase or cumulative rental cost exceeds the plan threshold; a long list of L‑codes is subject to PA.

O&P PA threshold: Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500.
HCPCS L‑code prior authorization list: Many L‑codes (for example L0170, L0456, L0462, L0480, L0624, L0710, L1005, L1310, L1740 series, and numerous others listed) require PA — include the specific L‑code on the request.
If the item is a prosthetic, note prosthetics are not classified as DME; submit PA per O&P rules and cost threshold.

Prior Authorization

Outpatient Therapy and Evaluation Codes Requiring Prior Authorization

Outpatient therapy evaluations, re‑evaluations and therapy services require prior authorization; the request process and contact vary by service. Submit evaluation/re‑evaluation PA requests via the Provider Portal; some outpatient therapy PAs must be submitted or contacted through OptumHealth Physical Health.

Portal submission: Submit evaluation and re‑evaluation PA requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.
Primary care provider origin requirement: The request for the evaluation/re‑evaluation codes must be submitted by a primary care provider.
Outpatient therapy phone submission: For outpatient therapy services and certain therapy CPT codes, call OptumHealth Physical Health at 800‑873‑4575 or use the notification number on the member’s ID card.
Examples of evaluation/re‑evaluation codes requiring PA: 97161–97168, 97110 series, 92521–92524 series, 92609–92610, 92626–92630, 96105, S9152 (where listed) and other codes enumerated in the outpatient therapy sections.

Documentation Required

Genetic Test Authorization and Laboratory Notification

Genetic and molecular tests require prior authorization for outpatient testing. When requesting authorization, identify the laboratory performing the test and the exact test name (CPT/HCPCS code). For sequencing tests, the ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare.

Include laboratory name and specific test name on the PA request — payment will be authorized only for CPT codes registered with the authorization/notification process.
Examples of genetic/molecular CPT codes listed: 81162, 81164, 81168, 81192–81194, 81228–81229, 81277–81279, 81338–81339, 81347–81349, 81351–81353, 81357, 81360, 81400–81408, 81410–81417, 81419–81420, 81431–81440, 81443–81460, 81479, 81507, 81518, 81520–81522, 81546, 81554, 81595, 81599 and many others included in the genetic testing listings.
Laboratory notification for sequencing: If sequencing is performed, the ordering provider must notify the lab; the lab will notify UnitedHealthcare as part of the PA/notification workflow.

Prior Authorization

Transplant / CAR T‑cell — Prior Authorization Contact and Process

Transplant and CAR T‑cell therapies require prior authorization and special case management. For these services (including agents/therapies listed), call the UnitedHealthcare Community and State Transplant Case Management team.

Transplant/CAR T‑cell prior auth contact: UnitedHealthcare Community and State Transplant Case Management — 888‑936‑7246.
Services included: solid organ transplants, ventricular assist devices, CAR T‑cell therapies (examples: Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) and related codes and supply items listed.
Operational note: For VAD notification, call the notification number on the member’s ID card and fax the form to the Optum VAD Case Management team at 855‑282‑8929 as instructed.

Denial Risk

Denial Risk and Implicit Prior Authorization Requirements

Where an explicit denial trigger is not stated, an implicit prior authorization requirement may still apply for services and codes listed. Always confirm PA requirements for the specific CPT/HCPCS/J‑code and place of service prior to providing service.

No explicit denial triggers are present for some groups of codes in this document, but PA is still required where indicated — lack of an explicit denial statement does not guarantee coverage without PA.
Check place‑of‑service exceptions (for example, some therapy codes are not subject to PA when billed with Place of Service = Home) and follow the site‑specific notes in each listing.

Prior authorization is required for cochlear and auditory implants as listed in the policy.

Example codesExamples provided in policy include CPT/HCPCS codes 69710, 69714, 69930 and L‑codes (e.g., L8619, L8690)

Continuous glucose monitor (CGM)

HCPCS codesA9276, A9277, A9278

Device typeContinuous glucose monitor (CGM) — durable medical device

Authorization requirementPrior authorization required when used with a type 2 diabetes diagnosis

Tezspire — product referenced

ProductTezspire (tezepelumab)

Associated codesPolicy references Tezspire and associates it with HCPCS/CPT entries (e.g., J3241 appears in the Tezspire section)

Authorization noteTezspire is listed in the policy with prior authorization referenced for its associated codes