Authorizations Precertifications HDHP Standard High UHC Plus
Note: The authorization information on this page is for GEHA's HDHP, Standard and High Option plan members. If the patient lives in Alabama, Arkansas, California, Delaware, Florida, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Mexico, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Virginia, Washington D.C., West Virginia, Wisconsin or Wyoming, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
For our other medical plans, visit Authorizations/Precertifications for Elevate and Elevate Plus members.
GEHA, like other federal health plans, requires providers to obtain authorization before some services and procedures are performed. You'll find more information on authorizations in the GEHA plan brochure. For quick reference, see the GEHA member's ID card.
The sources of our clinical guidelines can be found on our Sources of Utilization Management Criteria (PDF).
If Medicare or another group health insurance policy is the primary payer for these services, you do not need to obtain authorization.
If you are a member and you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor or the hospital must call GEHA within two business days following the day of the emergency admission, even if you have been discharged from the hospital.
Although your physician or hospital will precertify your stay, it is your responsibility to ensure that precertification is complete. Failure to precertify inpatient stays could result in a benefits reduction. It is not necessary to precertify hospital admissions outside the United States. For more details on your GEHA coverage when traveling, click on Outside the United States.
To check benefits and eligibility, call GEHA's Customer Care department at 800.821.6136.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission.
| Surgeries/Procedures Requiring Authorization | |
|---|---|
| Arthroplasty Procedures — Hips, knees, shoulders, elbows | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Back — Spinal fusions/Multi-level spinal surgeries/Artificial disc replacements | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. Please note: Charges billed by a facility for implantable devices, surgical hardware, etc., are subject to the Plan allowance, which is based on the provider’s cost plus 20% with submitted invoice, or two times the Medicare allowance without an invoice. Providers are encouraged to notify us on admission to determine benefits payable. |
| Bariatric Surgeries (Weight-loss surgery) |
Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization.
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Breast Procedures |
Breast Reconstruction
(except reconstruction for diagnosis of breast cancer) Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Gynecomastia: Reduction (unilateral/bilateral) For other cosmetic procedures Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Mammoplasty: Reduction (unilateral/bilateral) Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Mastectomy performed prophylactically Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
Cardiovascular
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Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Cartilage Implant | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Cochlear Implants | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Gender Affirmation Surgery | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Hysterectomy Surgery | Authorization is required.
Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Orthognathic Surgery Orthognathic surgery for the following conditions:
|
Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Osteochondral grafting of articular lesions including autologous chondrocyte transplants | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Panniculectomy/Abdominoplasty/Lipectomy | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
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Reconstructive Surgery
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Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Rhinoplasty/Sinus surgery | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission.
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| Sleep Study Program (In Lab) In-lab/outpatient/attended sleep study services for patients ages 18 or older that include:
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Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization.
Please note: Home sleep studies do not require authorization. Please only submit authorization requests for the procedures listed on the left. |
| Sympathectomy by Thoracoscopy or Laparoscopy | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Unlisted CPT codes, T-Codes, and procedures that are listed as experimental and investigational according to GEHA clinical coverage policies and/or could be considered experimental and investigational. | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Uvulopalatopharyngoplasty (UPP) | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Vein Surgeries (leg) | The following require authorization:
Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Services Requiring Authorization | |
|---|---|
| Applied Behavior Analysis (ABA) Therapy | Authorization is required. Providers should contact Optum at 855.583.3164 for authorization. Optum does not accept fax requests. Providers are required to complete an Applied Behavioral Analysis (ABA) assessment when requesting ABA services for the first time. The form does not need to be completed for members currently utilizing ABA services. This form gathers information needed to authorize the initial ABA assessment and is used to build the treatment plan. The form is updated during the concurrent review that generally takes place at 6 months. The ABA assessment must be approved before the ABA treatment starts. Once the assessment is complete, the provider can call and complete the clinical review over the phone. Follow this link to complete an online ABA assessment form. |
| Behavioral Health — Inpatient/Outpatient Care for Behavioral Health/Substance use Includes Residential Treatment centers, Partial Hospitalization Program and Intensive Outpatient Program |
Authorization is required. Providers should contact Optum Behavioral Health 877.585.9643 Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission.
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| Behavioral Health — Psychological and Neuropsychological Testing | Authorization is required for psychological and neuropsychological testing only if more than 8 hours of testing will be done. Providers should complete the online Optum authorization form.
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| Behavioral Health — ECT and TMS Electroconvulsive Therapy (ECT) Transcranial Magnetic Stimulation (TMS). |
Authorization is required. Providers should complete the online Optum authorization form. Authorization is required. Providers should contact Optum Behavioral Health. Refer to the back of the patient’s ID card under the heading Prior Authorization for the appropriate contact information and submission.
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| Speech-Generating Devices | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. |
| Cancer Treatment — non-surgical | Authorization is required. To obtain preauthorization, providers should log in to oncohealth.us and click on the Provider Login dialog box. If you choose an evidence-based treatment, you will receive immediate authorization approval. If you wish to submit a customized treatment plan, you may do so. However, customized plans require special review and may delay your authorization. If you experience any issues using the oncohealth.us site, please contact Oncology Analytics support at 888.916.2616. Please note: Based on the GEHA member's benefits, some medications must be obtained from CVS Caremark to avoid penalties to the member. For information about which drugs require specialty dispensing, please contact CVS Caremark at 855.240.0536. |
| Dialysis Services | Authorization is not required. However, GEHA does need the first date the member received dialysis for end-stage renal disease outpatient dialysis services. Providers should download a Dialysis Notification form, complete it and fax it to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. For inpatient care providers will need to contact UnitedHealthcare Choice Plus directly at 877. 585.9643 to obtain prior authorization. |
| Durable Medical Equipment | Authorization is sometimes required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. For cranial helmets, legible pictures with supporting documentation, medical records demonstrating cranial dimensions, prior therapies and response to such therapies may be needed. Please contact United Healthcare Choice Plus at 877.585.9643. These supplies and equipment do not require authorization:
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| Genetic Testing | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission. |
| Hospital — Medical/Surgical Inpatient Care | Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Please note that if the procedure or surgery requires authorization, it will be necessary to obtain approval for the procedure before having the hospital stay authorized. |
| Orthotics and Prosthetics | Authorization is required for some orthotics and prosthetics. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. Authorization is not required for mastectomy bras and prosthetics (L8000-L8039) with a diagnosis of breast cancer, or post mastectomy or lumpectomy. |
| Pain Management Epidural injections, FACET injections, Intrathecal pump insertion for pain (morphine, baclofen, etc.), spinal cord stimulators |
Authorization required for pain management. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. |
| Prescription Drugs | Some medications must be approved by GEHA and or CVS Caremark before they are a covered benefit. Members must make sure that their physicians obtain the prior approval/authorization for certain prescription drugs and supplies before coverage applies. Medication may be limited as to its quantity, total doses, duration of therapy, age, gender or specific diagnosis. Pre-approval/authorizations must be renewed periodically. See Prescription Drug Benefits in the GEHA Plan Brochure. To obtain these medications, contact CVS Caremark at 855.240.0536. |
| Specialty Prescription Drugs | Specialty Drugs are used to treat some severe medical conditions and are usually administered by injection or infusion. See Specialty Drug Benefits in the GEHA Plan Brochure. To obtain these medications, contact CVS Caremark at 855.240.0536. |
Radiology
|
Authorization is required. Ask your provider to call eviCore at 866.879.8317 or visit evicore.com before scheduling the procedure. Services that are not preauthorized will require retrospective review for medical necessity. If the service is approved, it is subject to a $100 penalty. |
| Skilled Nursing: Inpatient Includes Skilled Nursing, Long-Term Acute Care and Inpatient Rehabilitation facilities |
Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. |
| Skilled Nursing: Outpatient Includes Home Skilled Nursing Care, IV Therapy, Total Parenteral Nutrition (TPN)/ Intradialytic Parenteral Nutrition (IDPN) |
Authorization is not required, effective Jan. 1, 2021, for Home Skilled Nursing, IV Therapy, TPN and IDPN. Note: Please refer to the Specialty Prescription Drug authorization. For services before Jan. 1, 2021, authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. |
| Cognitive Rehabilitation |
Authorization is not required for Cognitive Rehabilitation, effective Jan. 1, 2021. For services before Jan. 1, 2021, authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. |
| Therapy Services: Physical, Occupational and Speech | Authorization is not required (effective Jan. 1, 2020) for Physical Therapy, Speech Therapy and Occupational Therapy for physical rehabilitation. |
| Therapy Services: Cardiac Rehabilitation | Authorization is required for services after 36 visits. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. |
| Therapy Services: Pulmonary Rehabilitation | Authorization is required for services after 24 visits. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. |
| Transplants (other than cornea or kidney) |
Authorization is required most transplants. For authorization and help identifying facilities within GEHA's transplant network, call 800.821.6136, ext. 3100. Authorization is not required for cornea or kidney transplants, which are paid under GEHA's medical benefit. |
| Wound Care Services: Outpatient Includes Hyperbaric Oxygen Therapy, wound vacuum devices, skin grafting and skilled-nursing services associated with the wound care |
Authorization is required. Providers will need to contact UnitedHealthcare directly at 877.585.9643 to obtain prior authorization. |
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