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
- Hospital admissions, including skilled nursing facilities and rehabilitation facilities
- Chemical dependency/substance abuse treatment or services
Services that require prior authorization
- Ambulatory surgery proposed to be done in an inpatient setting
- Arthroscopic debridement & lavage of the knee
- Bariatric surgery
- DEXA bone density study (ages up to and including 64)
- Patient education: Asthma education, Diabetes education, Nutritional programs, Smoking cessation program
- Durable medical equipment with cost in excess of $500.00 and all rentals
- Genetic testing and counseling
- High-risk pregnancy services2
- Home health services (including infusion services)
- Hyperbaric treatment
- In vitro fertilization services
- Injectible medications (click for examples)
- Occupational therapy/Physical Therapy - required after the first 40 units3 or 10 sessions
- Office surgery proposed to be done in an Ambulatory Surgery Center (ASC)
- Organ transplant services: transplant evaluations, organ donor services, transplant procedures
- Orthotics
- Out-of-state referrals - requires at least 2 weeks in advance
- PET scans
- Prosthetics with a cost in excess of $500
- Psychological testing (outpatient)
- Skilled nursing facility - room and board
- Speech therapy
- Stereostatic radiosurgery (e.g., gamma-ray radiosurgery, gamma-knife)
Types of medications that require prior authorization4
- Anti IgE Antibody, including but not limited to Xolair
- Anti-Tumor Necrosis (TNF)
- Antiviral agents
- Botulinum Toxin - Type A Botox
- Erythrocyte and Granuloctye Stimulating Factors
- Growth Hormone (Somatropin)
- Leuprolide acetate (Lupron)
- Oncological agents not listed as an indication for treatment of specific neoplasm in the ACCC Compendia-Based Drug Bulletin
- Parathyroid hormone
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
- We require notification of all pregnancies during the first trimester. In addition, we require notification as soon as it has been determined that a particular pregnancy may carry a high risk of complication.
- 1 unit = 15 minutes
- Medication list subject to change without notice. Contact Health Care Services to see if your medication is on the list.