UnitedHealthcare Medicare Prior Authorization Requirements ...

UnitedHealthcare Medicare Prior Authorization Requirements Effective January 1, 2018

General Information

This list contains prior authorization requirements for UnitedHealthcare Medicare Advantage (to include UnitedHealthcare Dual Complete and other plans listed in the "Included Plans" table below) participating care providers for inpatient and outpatient services. Health plans excluded from the requirements are listed in the "Excluded Plans" section on Page 2.

To request prior authorization, please submit your request online or by phone:

? Online: Use the Prior Authorization and Notification app on Link. Go to and click on the Link button in the top right corner. Then, select the Prior Authorization and Notification app tile on your Link dashboard.

? Phone: 877-842-3210

Prior authorization is not required for emergency or urgent care.

Plans with referral requirements: If a member's health plan ID card says "Referral Required," certain services may require a referral from the member's primary care provider and prior authorization obtained by the treating physician. You can find more information about the referral process in the 2018 UnitedHealthcare Administrative Guide for Commercial and Medicare Advantage Including UnitedHealthcare West Fee-for-Service at > Menu > Administrative Guides.

The following listed plans require prior authorization for in-network services:

Included Plans Subject to the UnitedHealthcare Provider Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement Medicare Advantage HMO, HMO-POS, PPO and Regional PPO plans including AARP? MedicareComplete?, UnitedHealthcare? The Villages? MedicareComplete?, UnitedHealthcare? MedicareComplete? plans for both individual and employer group members, and group retiree plans sold under UnitedHealthcare? Group Medicare Advantage (PPO) UnitedHealthcare Dual Complete? (HMO SNP), (HMO-POS SNP), (PPO SNP), (Regional PPO SNP) UnitedHealthcare? Chronic Complete (HMO SNP) UnitedHealthcare? Nursing Home and UnitedHealthcare? Assisted Living Plans (HMO SNP), (HMO-POS SNP), (PPO SNP) AARP? MedicareComplete? Mosaic (HMO) Care Improvement Plus? Products: Gold Rx (PPO SNP and Regional PPO SNP), Medicare Advantage (PPO and Regional PPO), Silver Rx (Regional PPO SNP), Dual Advantage (Regional PPO SNP) UnitedHealthcare Community Plan Medicare Advantage benefit plans subject to an additional manual, as further described in the benefit plan section of the 2018 UnitedHealthcare Administrative Guide for Commercial and Medicare Advantage Including UnitedHealthcare West Fee-for-Service at > Menu > Administrative Guides. As explained in the benefit plan section, some UnitedHealthcare Community Plan Medicare Advantage benefit plans are not subject to an additional manual and are therefore subject to the Administrative Guide.

Doc #: PCA-1-007895-09082017_09292017

UnitedHealthcare Medicare Prior Authorization Requirements Effective January 1, 2018

This prior authorization requirement does not apply to the following plans:

Excluded Plans The UnitedHealthcare Prior Authorization Program does not apply to the following excluded benefit plans. However, these benefit plans may have separate notification or prior authorization requirements. For details, please refer to the 2018 UnitedHealthcare Administrative Guide for Commercial and Medicare Advantage Including UnitedHealthcare West Fee-for-Service at > Menu > Administrative Guides. Florida: AARP? MedicareComplete? (HMO) ? Group 82958, 82960, 82963, 82969, 82977, 82978, 82980; AARP? MedicareComplete? Focus (HMO) ? Group 82970; AARP? MedicareComplete? Plan 2 ? Group 82962; UnitedHealthcare? The Villages? Medicare Complete? 1 (HMO) ? Group 82940; UnitedHealthcare? The Villages? Medicare Complete? 2 (HMO-POS) ? Group 82971; AARP? MedicareComplete? Choice (Regional PPO) ? Group 82955, 82956; AARP? MedicareComplete? Choice (PPO) ? Group 82957 Hawaii: AARP? MedicareComplete? Plan 1 ? Group 77000, 77007; AARP? MedicareComplete Choice? Essential ? Group 77003, 77008 Illinois: AARP? MedicareComplete? (HMO) ? Group 17243, 17244; AARP? MedicareComplete? Plan 1 (HMO) ? Group 18027, 18028; AARP? MedicareComplete? Plan 2 (HMO)? Group 55860; AARP? MedicareComplete? Access (HMO) ? Group 55306, 55307, 55430, 55431 Texas: UnitedHealthcare Dual Complete? (HMO SNP) ? Group 00012,; UnitedHealthcare Dual Complete Focus? (HMO SNP) ? Group 00303, 00305, 00307, 00310; AARP? MedicareComplete Focus? (HMO) ? Group 00300, 00304, 00306, 00309, 00315; AARP? MedicareComplete Focus Essential? (HMO) ? Group 00308 Utah: AARP? MedicareComplete? Plan 1 - Group 42000; AARP? MedicareComplete? Plan 2 - Group 42022; AARP? MedicareComplete Essential? - Group 42004; UnitedHealthcare Group Medicare Advantage ? Group 42020 Erickson Advantage? Plans UnitedHealthcare Medicare DirectSM (PFFS) Senior Dimensions Medicare Advantage Plans (Health Plan of Nevada) Medica HealthCare: Medica HealthCare Plans MedicareMax (HMO) ? Group 77700, 77701; Medica HealthCare Plans MedicareMax Plus (HMO SNP) ? Group 77702, 77703, 77704 Preferred Care Partners: Preferred Choice Broward HMO ? Group 78601; Preferred Choice Dade (HMO) ? Group 78600; Preferred Choice Palm Beach (HMO) ? Group 78606; Preferred Medicare Assist (HMO SNP) ? Group 78602, 78603, 78609; Preferred Medicare Assist Palm Beach (HMO SNP) ? Group 78607, 78608, 78610; Preferred Special Care Miami-Dade (HMO SNP) ? Group 78605 For the Medica and Preferred Care Partners of Florida groups above, please refer to the Medica Healthcare and Preferred Care Partners for Prior Authorization Requirements located at priorauth > Advance Notification and Plan Requirement Resources > Plan Requirement Resources.

Other benefit plans such as Medicaid, CHIP and Uninsured that aren't Medicare Advantage plans

Doc #: PCA-1-007895-09082017_09292017

UnitedHealthcare Medicare Prior Authorization Requirements Effective January 1, 2018

Prior authorization does not apply to procedures and services identified as a "Medicare prior authorization reduction" exclusion for the following states and health plan group numbers:

Exclusions for the Medicare prior authorization reduction program apply to:

? Contracted servicing care providers in Alabama, Arkansas, Connecticut, Idaho, Kansas, Missouri, North Carolina, Rhode Island and Wisconsin

OR

? These health plan group numbers:

12200 12236 12248 12310 12325 12365 12377 12389 12404 12416 12469 12558 12570 12582 12595 12617 12630 12644 12671 12685 12753 12787 12799 12816 12828 12860 12872 12885 12986 13211 13258 13275 13291 13308 13346 13452

12225 12237 12249 12311 12350 12366 12378 12390 12405 12417 12470 12559 12571 12583 12596 12618 12631 12647 12672 12686 12775 12788 12800 12817 12830 12861 12873 12886 12987 13212 13259 13276 13292 13311 13347 13453

12226 12238 12250 12312 12351 12367 12379 12391 12406 12418 12471 12560 12572 12584 12597 12620 12632 12657 12673 12688 12776 12789 12801 12818 12831 12862 12874 12889 12988 13213 13260 13277 13293 13314 13348 13454

12227 12239 12251 12313 12354 12368 12380 12392 12407 12419 12472 12561 12573 12585 12598 12621 12633 12658 12674 12689 12777 12790 12805 12819 12832 12863 12875 12892 12989 13225 13261 13278 13294 13315 13349 13456

12228 12240 12252 12314 12355 12369 12381 12393 12408 12420 12473 12562 12574 12586 12599 12622 12634 12659 12675 12690 12778 12791 12808 12820 12849 12864 12876 12894 12990 13226 13262 13281 13295 13319 13350 13457

12229 12241 12253 12315 12356 12370 12382 12394 12409 12421 12474 12563 12575 12587 12600 12623 12635 12660 12676 12694 12779 12792 12809 12821 12851 12865 12877 12895 12991 13240 13263 13284 13297 13321 13351 13458

12230 12242 12299 12316 12357 12371 12383 12395 12410 12422 12475 12564 12576 12588 12601 12624 12636 12661 12677 12698 12780 12793 12810 12822 12852 12866 12878 12898 13200 13250 13264 13285 13302 13323 13400 13459

12231 12243 12305 12317 12358 12372 12384 12396 12411 12423 12553 12565 12577 12590 12602 12625 12637 12662 12679 12699 12781 12794 12811 12823 12853 12867 12879 12899 13201 13252 13265 13286 13303 13325 13401 13460

12232 12244 12306 12320 12359 12373 12385 12397 12412 12424 12554 12566 12578 12591 12612 12626 12638 12663 12680 12701 12782 12795 12812 12824 12854 12868 12880 12951 13202 13253 13266 13287 13304 13327 13402 13461

12233 12245 12307 12322 12361 12374 12386 12398 12413 12425 12555 12567 12579 12592 12613 12627 12639 12664 12681 12702 12783 12796 12813 12825 12855 12869 12881 12975 13207 13254 13267 13288 13305 13343 13425 13501

12234 12246 12308 12323 12362 12375 12387 12399 12414 12467 12556 12568 12580 12593 12614 12628 12640 12666 12682 12751 12785 12797 12814 12826 12856 12870 12882 12976 13208 13256 13268 13289 13306 13344 13450 13502

12235 12247 12309 12324 12363 12376 12388 12402 12415 12468 12557 12569 12581 12594 12616 12629 12643 12667 12683 12752 12786 12798 12815 12827 12857 12871 12883 12985 13209 13257 13269 13290 13307 13345 13451 13503

Doc #: PCA-1-007895-09082017_09292017

UnitedHealthcare Medicare Prior Authorization Requirements Effective January 1, 2018

13504 13516 13554 13566 13600 13612 13624 13636 13648 13673 13685 13698 13717 13748 13760 13875 13912 13950 13971 15634 15646 15659 15990 16113 16130 16147 16159 16171 55114 55870 68094 68182

13505 13517 13555 13567 13601 13613 13625 13637 13649 13674 13686 13699 13718 13749 13761 13876 13916 13951 13972 15635 15647 15800 15991 16114 16131 16148 16160 16172 55313 55874 68118 68183

13506 13518 13556 13568 13602 13614 13626 13638 13650 13675 13687 13700 13719 13750 13762 13877 13920 13952 15500 15636 15648 15801 16101 16115 16132 16149 16161 16173 55336 55875 68124 68184

13507 13519 13557 13569 13603 13615 13627 13639 13651 13676 13688 13701 13720 13751 13763 13878 13924 13953 15501 15637 15650 15901 16103 16116 16133 16150 16162 27070 55369 55877 68125 68192

13508 13520 13558 13570 13604 13616 13628 13640 13665 13677 13689 13702 13721 13752 13764 13879 13928 13954 15600 15638 15651 15902 16104 16117 16134 16151 16163 27075 55370 55878 68132 68197

13509 13521 13559 13571 13605 13617 13629 13641 13666 13678 13690 13703 13722 13753 13765 13880 13932 13955 15627 15639 15652 15903 16105 16118 16137 16152 16164 55013 55377 55879 68138 97000

13510 13522 13560 13572 13606 13618 13630 13642 13667 13679 13691 13705 13723 13754 13766 13881 13936 13956 15628 15640 15653 15904 16106 16119 16139 16153 16165 55036 55394 55913 68139 97001

13511 13523 13561 13573 13607 13619 13631 13643 13668 13680 13692 13706 13724 13755 13800 13882 13937 13957 15629 15641 15654 15905 16107 16120 16140 16154 16166 55069 55400 55924 68140 97002

13512 13550 13562 13574 13608 13620 13632 13644 13669 13681 13694 13707 13726 13756 13801 13883 13938 13967 15630 15642 15655 15906 16108 16121 16141 16155 16167 55070 55401 55933 68141 97003

13513 13551 13563 13575 13609 13621 13633 13645 13670 13682 13695 13708 13735 13757 13802 13900 13939 13968 15631 15643 15656 15907 16110 16124 16142 16156 16168 55077 55411 68089 68142 97004

13514 13552 13564 13576 13610 13622 13634 13646 13671 13683 13696 13715 13746 13758 13840 13904 13944 13969 15632 15644 15657 15908 16111 16125 16143 16157 16169 55078 55412 68090 68153 97005

13515 13553 13565 13577 13611 13623 13635 13647 13672 13684 13697 13716 13747 13759 13850 13908 13946 13970 15633 15645 15658 15909 16112 16128 16144 16158 16170 55094 55414 68092 68181

Procedures and Services

Bone growth stimulator Electronic stimulation or ultrasound to heal fractures

Plan exclusions: ? Medicare prior authorization

reduction

Breast reconstruction (non-mastectomy) Reconstruction of the breast except when following mastectomy

Plan exclusions: None

Additional Information

Prior authorization required

Prior authorization required

Codes for Medicare Advantage Plans

20974 E0748

20975 E0749

20979 E0760

E0747

11920 19318 19330 19357

11921 19324 19340 19361

11922 19325 19342 19364

19316 19328 19350 19366

Doc #: PCA-1-007895-09082017_09292017

UnitedHealthcare Medicare Prior Authorization Requirements Effective January 1, 2018

Procedures and Services

Breast reconstruction (non-mastectomy) (cont'd)

Additional Information

Codes for Medicare Advantage Plans

19367 19371

19368 19380

19369 19396

19370 L8600

Prior authorization is not required for the following diagnosis codes:

Cochlear implants and other auditory implants A medical device, including those with a surgically implanted portion, within the inner ear and with an external portion to help persons with profound sensorineural deafness to achieve conversational speech

Prior authorization required

C50.019 C50.011 C50.012 C50.112 C50.119 C50.211 C50.219 C50.311 C50.312 C50.411 C50.412 C50.419 C50.512 C50.519 C50.611 C50.619 C50.811 C50.812 C50.911 C50.912 C50.919 C50.021 C50.022 C50.121 C50.129 C50.221 C50.222 C50.321 C50.322 C50.329 C50.422 C50.429 C50.521 C50.529 C50.621 C50.622 C50.821 C50.822 C50.829 C50.922 C50.929 C79.81 D05.00 D05.01 D05.02 D05.11 D05.12 D05.80 D05.82 D05.91 D05.92 Z90.10 Z90.11 Z90.12 Z42.1

C50.111 C50.212 C50.319 C50.511 C50.612 C50.819 C50.029 C50.122 C50.229 C50.421 C50.522 C50.629 C50.921 D05.90 D05.10 D05.81

Z85.3 Z90.13

69714 L8614 L8692

69715 L8619

69718 L8690

69930 L8691

Plan exclusions: ? Medicare prior authorization

reduction

Cosmetic and reconstructive procedures Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function

Prior authorization required

Advance notification required for services whether scheduled as inpatient or outpatient

Reconstructive procedures that treat a medical condition or improve or restore physiologic function

Plan exclusions: None

11960 15822 17106 21172 21181 21230 21255 21263 21299 28344

11971 15823 17107 21175 21182 21235 21256 21267 21740 30540

15820 15830 17108 21179 21183 21248 21260 21268 21742 30545

15821 15847 17999 21180 21184 21249 21261 21275 21743 30560

Doc #: PCA-1-007895-09082017_09292017

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download