Prior Authorization List Adults, FHP, CHP

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1 Please verify the member s benefits before requesting prior authorization (PA). Services vary within plans. To check member eligibility, please call Provider Services at or visit UnitedHealthcareOnline.com. Note: All out-of-network services require PA. Ambulance - Non-emergency transportation Bariatric surgery Blepharoplasty and eyebrow ptosis repair Breast reduction Cardiology PA program includes the following procedures, effective Nov. 1, 2013: Diagnostic heart catheterization Stress echocardiography Transthoracic echocardiography Cardiac implantable devices Chiropractic services - birth to age 20 require authorization after the initial visit Cosmetic surgery Dental - comprehensive services UnitedHealthcare Dental: Submit written PA requests only by mail, electronic data interchange or online at uhcproviders.com. Mail requests to: United Healthcare Community Plan Attn: Prior Authorizations P.O. Box 2076 Milwaukee, WI If you have questions before submitting a PA request, please call Durable medical equipment (DME) more than $500 and power mobility devices and wheelchair accessories regardless of dollar amount

2 Drug - Acthar HP Drug - Botulinum Toxins Drug - IVIG Drug - Makena Drug - Synagis Specialty pharmacy PA: Phone: Fax: Drug - Xolair Specialty pharmacy PA: Phone: Fax: Elective inpatient admissions Gynecomastia Home Health Care - All services in the home including but not limited to: Home infusion Nurse aide Private duty nursing Physical, occupational and speech therapies Skilled nursing Social worker Hospice services Personal Emergency Response System - installation and monthly rental (requires in-home evaluation). Phone: Fax: Long Term Care (personal care services/managed long term care/medical day/adult day)

3 Nursing facilities, long-term acute care, skilled nursing facility and extended care Panniculectomy and body contouring procedures Penile Implants - Drugs/devices or surgery for erectile dysfunction Radiology Program includes the following: Magnetic resonance image (MRI) Magnetic resonance angiography (MRA) Computerized axial tomography (CT) Positron-emission tomography (PET) Nuclear medicine Nuclear cardiology Rhinoplasty, septoplasty and turbinate resection Sleep study in the outpatient setting No PA required in the home setting Sterilization procedures - PA not required. Consent form required at time of claims submission. Hysterectomy Tubal ligation Vasectomy

4 Therapy/rehab (outpatient/office setting) including: Occupational therapy requires PA after the 12 th visit for each therapy for ages birth to 20. No PA required for 21 years and older. Benefit limit applies. Physical therapy requires authorization after the 12 th visit for each therapy for birth to age 20. No PA required for 21 years and older. Benefit limit applies. Speech therapy requires authorization after the12 th visit for each therapy birth to age 20. No PA required for 21 years and older. Benefit limit applies. Topical Oxygen Wound Therapy Transplant services Phone: Fax: Vein procedures

5 Prior Authorization List for UnitedHealthcare Dual Complete Ambulance - non emergency transportation Bariatric surgery Bone growth stimulator Breast reconstruction (non-mastectomy) Capsule endoscopy Cardiology PA program includes the following procedures, effective Nov. 1, 2013: Diagnostic heart catheterization Stress echocardiography Transthoracic echocardiography Cardiac implantable devices Cochlear and auditory implants Cosmetic and reconstructive surgery Dental - comprehensive services UnitedHealthcare Dental: Submit PA requests in writing only by mail, electronic data interchange or online at Durable medical equipment (DME) regardless of dollar amount: power mobility devices, accessories, lymphedema pumps and pneumatic compressors. United Healthcare Community Plan Attn: Prior Authorizations P.O. Box 2076 Milwaukee, WI If you have questions before submitting a PA request, please call DME more than $1000

6 Prior Authorization List for UnitedHealthcare Dual Complete Home care Home care - nutritional Hyperbaric oxygen therapy Joint replacement Muscle flap Orthognathic Orthotics more than $1000 Potentially unproven services Prosthetics more than $1000 Proton beam Radiology program includes: Magnetic resonance image (MRI) Magnetic resonance angiography (MRS) Computerized axial tomography (CT) Positron-emission tomography (PET) Nuclear medicine Nuclear cardiology Septoplasty/rhinoplasty Sleep apnea procedures and surgeries Spinal stimulator Spine surgeries Transplant services Phone: Fax: Vagus nerve stimulation Vein procedures

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