June 01, 2022

Medicaid: Prior authorization required for all shoulder surgery service codes beginning Aug. 1, 2022

Effective Aug. 1, 2022, we will require prior authorization for all shoulder surgery service codes for UnitedHealthcare Community and State health plan members.

  • Prior authorization is not required for emergency or urgent services
  • We will deny claims if prior authorization is not on file before the date of service

Included states
The prior authorization requirement will be deployed on Aug. 1, 2022, for the following state plans:

  • Arizona
  • Florida
  • Michigan
  • Missouri
  • Texas
  • Virginia
  • Washington
  • Wisconsin

The prior authorization requirement will be deployed on Sept. 1, 2022, for the following state plans:

  • Maryland
  • New York
  • Rhode Island

Medical necessity review
When you submit a prior authorization request starting Aug. 1, 2022, we will review your request for medical necessity. We will provide an authorization, if appropriate, and send that determination to you and your patient.

A site of service review may be performed when the case is reviewed to determine if the location where the services will be performed is medically necessary.

You can submit requests for these services with dates of service on or after Aug. 1, 2022, on the UnitedHealthcare Provider Portal using your One Healthcare ID and the Prior Authorization and Notification tool. If you’re unable to use the portal, call Provider Services at 877‐842‐3210 to submit a request by phone.

Questions?
For the full list of shoulder surgery codes, reference the list of current prior authorization plan requirements.

PCA-1-22-01419-VC-News