Optum Prior Authorization Lookup
Latest Optum prior authorization updates25
- Prior AuthAdministrative/Operational PolicyEff. 2027-01-01Kentucky Medicaid program changes and related fiscal provisions (HB 695/HCS1)Summarizes a Kentucky bill (HB 695/HCS1) that restricts Department for Medicaid Services authority to change eligibility/coverage without the General Assembly, authorizes a community engagement waiver, creates a pharmaceutical rebate fund, limits psychoeducational behavioral health service units, reinstates prior authorization requirements, and adds reporting and procurement requirements affecting DMS and MCOs.All Optum updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-06-15Authorization required for Arizona Medicaid IOP services - billing codes S9480 and H0015This policy requires prior authorization for Intensive Outpatient Program (IOP) services billed to Arizona Medicaid/AHCCCS for mental health and substance use disorder treatment beginning June 15, 2026, and explains submission, documentation, and decision processes affecting providers delivering these services.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-05-01Behavioral health prior authorization for Nebraska Heritage Health / UnitedHealthcare Community PlanLists behavioral health services and specific revenue/CPT/J-code items that require prior authorization for members of the Nebraska Heritage Health / UnitedHealthcare Community Plan; applies to in-network and out-of-network non-emergency providers serving plan members in Nebraska.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-05-01Missouri Healthnet Medicaid and CHIP Behavioral Health - Prior Authorization RequirementsDefines behavioral health services that require prior authorization for UnitedHealthcare Community Plan members under Missouri Healthnet Medicaid and CHIP; applies to in-network and out-of-network providers delivering behavioral health services to Missouri Medicaid and CHIP members.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-05-01Prior authorization for behavioral health servicesThis document lists behavioral health services that require prior authorization for UnitedHealthcare Community Plan of Wisconsin Medicaid Managed Care members and explains exceptions (emergency services and in-network rules). It affects participating and out-of-network behavioral health providers serving Wisconsin Medicaid Managed Care members.All Optum updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-04-01Behavioral health prior authorization for Hawaii MedicaidLists behavioral health services and procedure codes that require prior authorization for UnitedHealthcare/Optum Hawaii Statewide Medicaid Managed Care members, including Long-Term Services and Supports; applies to participating and non-participating providers in Hawaii.All Optum updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Hawaii Medicaid Supplemental Clinical Criteria — Applied Behavior Analysis (ABA)State-specific supplemental clinical criteria governing coverage, prior authorization, delivery, and administrative requirements for ABA services for Hawaii Medicaid (EPSDT-eligible) members, including screening, diagnosis, assessment, treatment planning, and provider credentialing.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Kansas Long Term Care — Behavioral health prior authorization requirements for Kansas LTCDefines behavioral health services and specific revenue/procedure codes that require prior authorization for UnitedHealthcare Community Plan of Kansas Medicaid Long Term Care (LTC) members; applies to participating and non‑participating providers serving Kansas LTC members.All Optum updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-01-01Prior Authorization Code List — UnitedHealthcare Exchange Plans (Colorado)Lists services and procedure codes requiring prior authorization for participating behavioral health providers for UnitedHealthcare Exchange Plans members in Colorado; affects providers delivering inpatient and outpatient behavioral health services to those members.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Prior authorization for behavioral health servicesDefines which behavioral health services and specific procedure/revenue codes require prior authorization for UnitedHealthcare Community Plan members under Kansas Medicaid; applies to participating and non-participating providers serving Kansas Medicaid members.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Prior authorization for behavioral health servicesThis document lists behavioral health services and procedure codes that require prior authorization for UnitedHealthcare Community Plan members in the Washington Integrated Medicaid Managed Care contract, and applies to participating and non-participating providers delivering these services in Washington state.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Wyoming Gold Card prior authorization waivers for behavioral health servicesThis document governs Wyoming-specific Gold Card prior authorization exemptions for certain behavioral health services provided to eligible fully insured commercial and Individual Exchange plan members, applying to NPI-specific in-network providers; it does not apply to Medicare Advantage or Medicaid members.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-11-01Medicare Prior Authorization CodesLists behavioral health services and procedure codes that require prior authorization for Medicare Advantage members and notes special rules for OTPs, PHP/IOP, TMS, and psychological testing. Affects providers delivering behavioral health services to Optum Medicare Advantage plan members.All Optum updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Family-based Intensive Treatment (FIT) coverage criteria for Medicaid membersDefines coverage, prior authorization, billing, and operational requirements for Family-based Intensive Treatment (FIT) for Medicaid members under age 21 at acute risk of hospitalization or recently hospitalized, effective October 1, 2025. Applies to providers delivering FIT in the specified state program.All Optum updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Supplemental Clinical Criteria: Psychological and Neuropsychological TestingSupplemental clinical criteria governing provider qualifications, coverage rationale, limitations, and developmental/automated testing guidance for psychological and neuropsychological testing for behavioral health benefit plans managed by Optum; applies to reviewers and providers when determining coverage and prior authorization. Does not apply to Department of Managed Health Care-regulated Commercial Health Plans in California.All Optum updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-01Behavioral Health Prior Authorization Code List — TennCare and CoverKidsLists behavioral health services and billing codes that require prior authorization for Tennessee TennCare and CoverKids members served by UnitedHealthcare Community Plan; applies to inpatient stays, out-of-network providers, TMS, ABA, residential, and related services.All Optum updates
- Prior AuthClinical/Medical PolicyEff. 2025-08-19Texas Medicaid: Autism Services (State‑Specific Supplemental Clinical Criteria)State-specific supplemental clinical criteria governing Medicaid-covered autism services, including Applied Behavior Analysis (ABA), for Texas children and youth (age ≤20) and requirements for prior authorization and documentation.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-07-01Prior Authorization Requirements for New Jersey FamilyCare Behavioral Health ServicesThis document lists behavioral health services and procedure codes that require prior authorization for New Jersey FamilyCare (UnitedHealthcare Community Plan of NJ) members and provides notes on exceptions and where to find additional guidance. It affects participating and non-participating behavioral health providers serving NJ FamilyCare members.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-07-01Prior authorization requirements for behavioral health services — UnitedHealthcare Community Plan of KentuckyThis document governs reinstated prior authorization requirements for specified behavioral health services for UnitedHealthcare Community Plan of Kentucky members and explains how providers must request authorizations; it affects in‑network and out‑of‑network providers delivering those services in Kentucky.All Optum updates
- Prior AuthClinical/Medical PolicyEff. 2025-06-01Applied Behavior Analysis (ABA) — New Mexico Supplemental Clinical CriteriaState-specific supplemental clinical criteria governing medical necessity, provider requirements, prior authorization, and service staging for ABA services under New Mexico Medicaid; applies to members of Optum-managed behavioral health plans in the state. Affects providers (AEPs, BAs, BCaBAs, BTs, SCPs) and families seeking ABA services.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-06-01Prior authorization requirements for behavioral health services (Pennsylvania CHIP)Lists behavioral health services and specific procedure/revenue codes that require prior authorization for UnitedHealthcare Community Plan members under the Pennsylvania CHIP; applies to participating and out-of-network providers in Pennsylvania.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-06-01Prior authorization requirements for behavioral health services (Pennsylvania CHIP)All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-03-01Behavioral health prior authorization quick reference — UnitedHealthcare Community Plan of Nebraska (Heritage Health)Lists behavioral health services and revenue/CPT/J-code services that require prior authorization for UnitedHealthcare Community Plan of Nebraska (Heritage Health) Medicaid; applies to in- and out-of-network providers and covers emergency/notification exceptions.All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-03-01Behavioral health prior authorization requirements for Complete Care members (AZ)Lists behavioral health services and revenue/CPT codes that require prior authorization for UnitedHealthcare Community Plan of Arizona Complete Care Medicaid members (includes CRS-designated members; excludes CRS Only).All Optum updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-03-01Behavioral health prior authorization requirements — UnitedHealthcare Community Plan (District of Columbia)Lists behavioral health services and specific procedure/revenue codes that require prior authorization for UnitedHealthcare Community Plan members in the District of Columbia Medicaid Managed Care contract; applies to participating and non‑participating providers delivering behavioral health services to plan members.All Optum updates
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Tool Description
Search Optumprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
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