Prior Authorizations and Notifications
Plans administered by Optum Behavioral Health require authorization or notification for specialty outpatient services and most inpatient services
Review the code lists for details
Medicare Advantage Plans (Coming soon)
Please note the included Medicare Prior Authorization list can be used to confirm DSNP Medicare services prior authorization requirements only. The Medicare Prior Authorization list is not inclusive of the Medicaid services and prior authorization requirements for DSNP members. To confirm the Medicaid services prior authorization requirements, please be sure to also check the coordinating state and product specific Medicaid Prior Authorization list.
For all of the states listed below, Optum does not manage the Medicaid benefits. Therefore, the Medicaid prior authorization requirements will have to be confirmed with the appropriate Medicaid Managed Care Organization.
- Delaware, Georgia, Iowa, Oklahoma, and Pennsylvania
Prior Authorization Requirements Being Eliminated for ECT
Effective Nov. 1, 2023, Optum Behavioral Health began eliminating prior authorization requirements for 3 codes specific to Electroconvulsive Therapy (ECT). For treatment that begins on or after Nov. 1, 2023, providers no longer need to request prior authorization for members covered by any UnitedHealthcare Commercial or Medicare Advantage plan, and for UnitedHealthcare Community Plans (Medicaid) in 17 states. Requirements will change for other health plans throughout 2024. Providers will be notified in advance of those changes.
Applied Behavior Analysis requirements
Authorization of ABA treatment is a 2-step process for most health plans. It begins with a comprehensive assessment to confirm the autism spectrum disorder diagnosis. Then, you must request prior authorization and submit a treatment plan before providing services.
Reminder – Check member benefit plans at each visit
The Provider Express secure portal makes it easy to review a member’s benefit plan and verify what services require authorization or notification. You can also use the secure portal to quickly submit authorization requests and check the status of requests in process.
Additional resources
Online Submission Instructions
Submitting requests through the secure portal is the first step toward a timely decision on the request.
State-Specific Forms
If you are faxing or mailing a request to Optum, some states require you to complete specific forms.
Clinical Criteria
Optum uses evidence-based clinical criteria from a variety of resources to help make coverage determinations.
Patient and Provider Resources
Access toolkits, assessments, select medication information and more to help you provide care to members.