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 1. Home
 2. Prior Authorization and Notification

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For information on the Change Healthcare cyber responseopen_in_new




PRIOR AUTHORIZATION AND NOTIFICATION

Prior authorization information and forms for providers. Submit a new prior
auth, get prescription requirements, or submit case updates for specialties.

Health care professionals are sometimes required to determine if services are
covered by UnitedHealthcare. Advance notification is often an important step in
this process. Because requests vary, it is important that you verify the
specific clinical requirements of each request. 

 


DIGITAL TOOLS

We’ve designed our digital tools to help you seamlessly submit and verify your
prior authorizations and advance notifications in real time. While you’re in the
tool, you can also easily check requirements, get status updates and more.




MEDICAL PROFESSIONAL DIGITAL TOOLS


UnitedHealthcare Provider Portal – The Prior Authorization and Notification tool
allows you to submit inquiries, process requests and get status updates. 


Sign inopen_in_new to the portal

 * Prior Authorization and Notification quick start guideopen_in_new
 * Prior Authorization and Notification interactive guideopen_in_new


Electronic Data Interchange (EDI) allows you to securely and electronically
submit and receive batch transactions for multiple cases. 




PHARMACY DIGITAL TOOLS


PreCheck MyScript® integrates directly within your EMR so you can easily run a
pharmacy trial claim and get real-time prescription coverage details.


Sign inopen_in_new to use PreCheck MyScript.






MEDICAL PROFESSIONAL RESOURCES 

Crosswalkopen_in_new
For commercial, Individual Exchange, Medicare Advantage, and Community plan
members, the crosswalk table will help you determine next steps when you need to
provide a service different from the prior authorized service. Note: An X in the
table means the crosswalk is available. An N/A in the table means Crosswalk is
not available. You can find more helpful details in the Crosswalk information
sheetopen_in_new. 

Advance notification
Take this first step to help you determine coverage based on medical necessity.
Please note, prior authorization may still be required. 

Peer-to-peer requestsopen_in_new
Peer-to-peer requests are made prior to submitting an appeal. Don’t fill out
this form if your appeal has already been initiated.

Regulatory
You can find state-required information regarding services that require
pre-service review.


PHARMACY RESOURCES

Clinical and specialty pharmacy
Certain medications require notification and review to determine coverage under
pharmacy benefits. You can view clinical pharmacy requirements here.

Drug lists
Get pharmacy coverage information including drug lists, supply limits, step
therapy and infusion care.

Community Plan prescribers
Access forms used for the manual submission of specific drug prior
authorizations.






SPECIALTY SPECIFIC RESOURCES


CARDIOLOGY



See requirements Cardiology


ONCOLOGY



See requirements Oncology


RADIOLOGY



See requirements Radiology


GENETIC AND MOLECULAR TESTING



See requirements Genetic and Molecular Testing


GASTROENTEROLOGY



See requirements Gastroenterology



PRIOR AUTHORIZATION NEWS

See all news arrow_forward

June 28, 2024


MICHIGAN: PRIOR AUTHORIZATION UPDATES FOR PROVIDER ADMINISTERED MEDICATIONS



Starting Oct. 1, 2024, we’ll require prior authorization for some provider
administered medications in Michigan.

Read Full Update Michigan: Prior authorization updates for provider administered
medications

June 28, 2024


MASSACHUSETTS MEDICAID: USE APPROPRIATE BILLING CODES FOR FASTER DME CLAIMS
PROCESSING



Correct billing code information for power wheelchair repairs for
UnitedHealthcare Community Plan of Massachusetts plan members.

Read Full Update Massachusetts Medicaid: Use appropriate billing codes for
faster DME claims processing

June 28, 2024


UPDATES TO ONCOLOGY AND HEMATOLOGY PRIOR AUTHORIZATION CODES FOR MANY PLANS



Starting Oct. 1, 2024, we’ll require prior authorization for diagnosis of
oncologic or hematologic conditions.

Read Full Update Updates to oncology and hematology prior authorization codes
for many plans

June 28, 2024


HOME HEALTH AND PRIVATE DUTY NURSING SERVICES PRIOR AUTHORIZATION PROCESS



Home health and private duty nursing service prior authorization requests are
assessed based on medical necessity and more.

Read Full Update Home health and private duty nursing services prior
authorization process

June 28, 2024


NEW PRIOR AUTHORIZATION REQUIREMENTS FOR CGMS



As of Sept. 1, we’re making updates to continuous glucose monitor coverage for
UnitedHealthcare Medicare Advantage plans.

Read Full Update New prior authorization requirements for CGMs

June 28, 2024


NEW ONLINE UTILIZATION MANAGEMENT REQUIREMENT



You will be required to submit utilization management requests online for
patients delegated to Optum Health Networks.

Read Full Update New online utilization management requirement



Expand All add_circle_outline
HOW DO I SUBMIT A PRIOR AUTHORIZATION, ADVANCE NOTIFICATION OR ADMISSION
NOTIFICATION?

expand_more

There are several ways you can submit prior authorizations, advance
notifications and admission notifications (HIPAA 278N):

 1. Prior authorization and notification tools: These digital options, available
    in the UnitedHealthcare Provider Portalopen_in_new, allow you to seamlessly
    submit your requests in real time
 2. EDI: This digital solution allows you to automate prior authorization and
    notification tasks
 3. Provider Services: If you’re unable to use the provider portal, call
    877‐842‐3210 to submit a request
 4. Fax: You can submit requests by fax to 855‐352‐1206. Please note: This
    option is only available for the following commercial plans: Massachusetts,
    Nevada, New Mexico and Texas.




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