Services that are medically necessary and a covered benefit under the member's health plan are usually paid for, but certain services require prior authorization before they can be provided. These services, especially those that may result in expensive procedures, undergo the prior authorization process to ensure those services will be covered.
We will make a decision within 15 days of receipt of your request for prior authorization. Read more about "medical necessity," and details about services which require prior authorization in our Provider Handbook. Health Care Services is available to assist you with all prior authorization requests and advance notification requirements.
Services that require 72 hours advance notification1
- Elective hospital admissions (including skilled nursing facilities and rehabilitation facilities) when possible. UHA requires notification of emergency and non-elective admissions within one (1) business day of admission.
- Chemical dependency/substance abuse treatment or services
Ambulatory Surgery Center (ASC) Procedures
See a list of services that do not require prior authorization when performed in an ASC or physician's office.
Services that require prior authorization
- Inpatient and Ambulatory (Outpatient) Surgical Procedures
- Ambulatory surgery proposed to be done in an inpatient setting
- Bariatric surgery
- Hyperbaric treatment
- Office surgery proposed to be done in an Ambulatory (Outpatient) Surgery Center
- Organ transplant Services: transplant evaluations, organ donor services, transplant procedures
- Stereotactic radiosurgery (e.g. gamma-ray radiosurgery [gamma-knife])
- In vitro fertilization services
- Diagnostic Testing And Radiology Procedures
- CCTA – Coronary Computed Tomography Angiography
- DEXA central bone density study (ages up to and including 64)
- Genetic testing
- PET scans
- Sleep Study —
(CPT code 95810 - Polysomnography ordered WITHOUT CPAP titration)
REQUIRES prior authorization
(CPT code 95811 – Polysomnography ordered WITH CPAP titration)
DOES NOT require prior authorization - Psychological Testing
- Durable Medical Equipment (DME) and Supplies
- Durable medical equipment purchase price and total rental cost greater than $500
- Orthotics
- With HCPCS codes: L1832 L1906 L1930 L1970 L2112 L2220 L3805 L3982 L4360
- Foot orthotics are not covered except for certain diabetic conditions
- Out-Of-State Services
- Out-of-state requests (require at least 2 weeks for processing)
- Prosthetics
- Prosthetics with cost more than $500
- Rehabilitative Services
- Physical therapy (requires prior authorization after the first 48 units or 12 sessions; 1 unit = 15 minutes)
- Occupational therapy (requires prior authorization after the first 48 units or 12 sessions; 1 unit = 15 minutes)
- Speech therapy
- Home Health Services Including Infusion Services
- Home Health Services after the first 12 visits
- Injectables And Other Pharmacological Agents
- Anti-Tumor Necrosis Factor (TNF) including but not limited to Enbrel, Humira, Raptiva, Remicade
- Antiviral agents including but not limited to RespiGam, Synagis, Fuzeon
- Botulinum Toxin – Type A (Botox)
- Erythrocyte and Granulocyte Stimulating Factors including but not limited to Darbepoetin alfa (Aranesp), Epoetin Alfa (Eprex, Epogen, Procrit), Filgastrim (Neupogen), Pegfilgrastim (Neulasta)
- Fabrazyme
- Growth Hormone (Somatropin) including but not limited to, Genotropin, Genotropin Miniquick, Humatrope, Norditropin, Nutropin, Nutropin AQ, Nutropin Depot, Saizen, Serostim
- Leuprolide acetate (Lupron)
- Oncological agents not listed in Compendia-Based Drug Bulletin as an indication for treatment of specific neoplasm in the ACCC Compendia-Based Drug Bulletin
- Parathyroid hormone including but not limited to Forteo
- Actiq (Fentanyl Citrate Oral Transmucosal)
- Anabolic Androgens
- Emend (Aprepitant)
- Iressa (Gefitinib)
- Lotronex (Alosetron Hydrochloride)
- Nexavar (Sorafenig)
- OxyContin (Oxycodone Hcl Controlled Release)
- Progesterone Micronized Powder
- Progesterone Powder
- Revlimid (Lenalidomide)
- Sutent (Sunitinib)
- Thalomid (Thalidomide)
- Tykerb (Lapatinib)
- Zyvox (Linezolid)
- Injectable medications (covered under medical plan):2
- Oral Medications (covered under prescription drug plan):2
We require that all participating providers comply with the prior authorization, concurrent and retrospective review processes. Services denied for lack of prior authorization cannot be billed to the UHA member.
Cosmetic procedures are not covered benefits.
- Except in cases of emergency
- Medication list subject to change without notice. Contact Health Care Services to see if your medication is on the list