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Prior Authorization Requirements

In order to initiate a prior authorization request, the following essential information (EI) is required:

  • Member name
  • Member number or Medicaid number
  • Member date of birth
  • Requesting provider’s name
  • Requesting provider’s National Provider Identifier (NPI)
  • Rendering provider’s Name
  • Rendering Provider’s National Provider Identifier (NPI)
  • Rendering Provider’s Tax Identification Number (TIN)
  • Service requested – use Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT), as appropriate
  • Service requested start and end dates
  • Quantity of service units requested based on the CPT, HCPCS, or CDT requested

If a prior authorization request does not contain each of the essential information data points, the request will not be created and will be returned to the provider with guidance on which information is missing.

NOTE: Please ensure all required clinical documentation is included to avoid delays in service for our shared members.

For information about what other documentation might be required, go to Medical Record Requirements for Pre-Service Reviews. 

Current Prior Authorization Requirements

UnitedHealthcare Community Plan - Children's Health Insurance Program (CHIP)

UnitedHealthcare Community Plan - Connected Texas (Medicare-Medicaid Plan)

UnitedHealthcare Community Plan - STAR

UnitedHealthcare Community Plan - STAR Kids

UnitedHealthcare Community Plan - STAR+PLUS

UnitedHealthcare Medicare Solutions & UnitedHealthcare Community Plan (Dual Special Needs Plan) Prior Authorization Requirements

 

Previous Prior Authorization Requirements

UnitedHealthcare Community Plan - Children's Health Insurance Program (CHIP)

UnitedHealthcare Community Plan - Connected Texas (Medicare-Medicaid Plan)

UnitedHealthcare Community Plan - STAR

UnitedHealthcare Community Plan - STAR Kids

UnitedHealthcare Community Plan - STAR+PLUS

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