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 1. Home
 2. Prior Authorization and Notification

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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.


OUR NATIONAL GOLD CARD PROGRAM

Modernizing the prior authorization process, this program is available for
provider groups meeting eligibility requirements.

Get the details


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

November 27, 2024


REVIEW TEXAS MEDICAID AND HEALTHCARE PARTNERSHIP CPW PROGRAM CHANGES



On Dec. 1, we won’t require prior authorizations for the Texas Medicaid and
Healthcare Partnership Children and Pregnant Women program services.

Read Full Update Review Texas Medicaid and Healthcare Partnership CPW program
changes

October 31, 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

October 31, 2024


VERIFY ADDRESS TO AVOID APWUHP CLAIM APPEAL DELAYS



Claim appeals addressed incorrectly may be delayed or go unanswered. And APWUHP
members to be assigned a new group number.

Read Full Update Verify address to avoid APWUHP claim appeal delays

October 31, 2024


CHANGES TO GENETIC AND MOLECULAR TESTING COVERAGE AND PRIOR AUTHORIZATION
REQUIREMENTS



Certain CPT codes associated with pharmacogenetic testing will no longer be
covered or require prior authorization.

Read Full Update Changes to genetic and molecular testing coverage and prior
authorization requirements

October 31, 2024


UPDATES TO PHARMACY PRIOR AUTHORIZATION AND STEP THERAPY REQUIREMENTS



Effective Jan. 1, 2025, Optum Rx will manage pharmacy prior authorizations and
step therapy requests for Golden Rule plan.

Read Full Update Updates to pharmacy prior authorization and step therapy
requirements

October 31, 2024


MEDICARE ADVANTAGE: PRIOR AUTHORIZATION RESOURCES FOR OUTPATIENT THERAPY AND
CHIROPRACTIC SERVICES



View helpful resources regarding prior authorization for PT, OT, ST and
chiropractic services.

Read Full Update Medicare Advantage: Prior authorization resources for
outpatient therapy and chiropractic services



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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