Optum behavioral health uses clinical criteria, based on sound clinical evidence, to make coverage determinations, as well as to inform discussions about evidence-based practices and discharge planning. In using its clinical criteria, Optum Behavioral Health takes individual circumstances and the local delivery system into account when determining coverage of behavioral health services. To learn more about the clinical criteria used by Optum Behavioral Health to make coverage decisions, go to providerexpress.com > Clinician Resources > Guidelines Policies and Manuals > Clinical Criteria. See other resources below.
The cardiology prior authorization and notification programs support the consistent use of evidence-based, professional guidelines for cardiology procedures. They were designed with the help of physician advisory groups to encourage appropriate and rational use of cardiology services. Using them helps reduce risks to patients and improves the quality, safety and appropriate use of cardiac procedures. You can call 866-889-8054 from 7 a.m. -- 7 p.m., local time, Monday – Friday for assistance. The system will enable you to continue with the request process or notify you that prior authorization is not needed.
The oncology prior authorization and notification programs aim to increase quality and patient safety by increasing compliance with evidence-based standards of care. For assistance, call 866-604-3267 Monday - Friday, 8 a.m. - 5 p.m. Central Time.
The pharmacy prior authorization program is designed for care providers prescribing drugs that require prior authorization review prior to member distribution. UnitedHealthcare Community Plan’s Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health so we’re aligned with national treatment standards.
Certain outpatient physical health therapies delivered through both Optum and UnitedHealthcare to UnitedHealthcare Community Plan members require a prior authorization to begin and continue certain services. Some of these prior authorization requirements differ from the Texas Medicaid Provider Procedures Manual. Where there is a difference, our requirements need to be met for prior authorization for our UnitedHealthcare Community Plan members.
For supporting medical necessity documentation, fax the following form(s), as applicable, to 877-470-7613:
The radiology prior authorization and notification programs support the consistent use of evidence-based, professional guidelines for diagnostic imaging procedures. They help reduce risks to patients and improve the quality, safety and appropriate use of imaging procedures.