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Authorizations/Precertifications HDHP, Standard and High Option members

Note: The authorization information on this page is for GEHA's HDHP, Standard and High plan members. 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 should call UnitedHealthcare at 877.585.9643.
Back — Spinal fusions/Multi-level spinal surgeries/Artificial disc replacements Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.

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 should call UnitedHealthcare at 877.585.9643.
Breast Procedures Breast Reconstruction (except reconstruction for diagnosis of breast cancer)
Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.

Gynecomastia: Reduction (unilateral/bilateral)
Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.

Mammoplasty: Reduction (unilateral/bilateral)
Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.

Mastectomy performed prophylactically
Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Cardiovascular
  • Catheter Ablation for Atrial Fibrillation
  • Cardiac Event Monitoring
  • Endovascular Revascularization Procedures
  • Percutaneous Patent Foramen Ovale (PFO) Closure
 Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Cartilage Implant Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Cochlear Implants Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Gender Affirmation Surgery Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Hysterectomy Surgery Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Orthognathic Surgery
Orthognathic surgery for the following conditions:
  • severe sleep apnea only after conservative treatment of sleep apnea has failed
  • cleft palate and Pierre Robin Syndrome
 Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Osteochondral grafting of articular lesions including autologous chondrocyte transplants Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Panniculectomy/Abdominoplasty/Lipectomy Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.

Reconstructive Surgery

  • Blepharoplasty or other types of eyelid surgeries, browlift
  • Liposuction and scar revisions
Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Rhinoplasty/Sinus surgery Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
  • Septoturbinoplasty does not require authorization when performed alone.
  • Septoturbinoplasty does require review when combined with either a rhinoplasty or a sinus surgery.
Sleep Study Program (In Lab)
In-lab/outpatient/attended sleep study services for patients ages 18 or older that include:
  • 95805
  • 95807
  • 95808
  • 95810
  • 95811
 Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.

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 should call UnitedHealthcare at 877.585.9643.
Unlisted CPT codes, T-Codes, and procedures that are listed as experimental and investigational according to UnitedHealthcare clinical coverage policies and/or could be considered experimental and investigational. Authorization is required. Providers should call UnitedHealthcare at 877.585.9643
Uvulopalatopharyngoplasty (UPP) Authorization is required. Providers should call UnitedHealthcare at 877.585.9643
Vein Surgeries (leg) Authorization is required. Providers should call UnitedHealthcare at 877.585.9643
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.

Complete an online ABA assessment form
Speech-Generating Devices Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Cancer Treatment — non-surgical Authorization is required. To obtain preauthorization, providers should log in to oncohealth.us, select Provider Login dialog box and select GEHA. If you experience any issues using the oncohealth.us site or if you need access credentials for the portal, please contact OncoHealth Client Support at 888.916.2616.

If you choose an evidence-based treatment, you will receive an 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.

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 816.257.3302. For help, call 800.821.6136, ext. 3100.

For inpatient care, please see Hospital — Medical/Surgical Inpatient Care.
Durable Medical Equipment Authorization is sometimes required. Providers should call UnitedHealthcare at 877.585.9643.
Genetic Testing Authorization is sometimes required. Providers should call UnitedHealthcare at 877.585.9643.
Hospital – Medical/Surgical Inpatient Care

Behavioral Health – Inpatient
Care for Behavioral Health/Substance Use, including Residential Treatment Centers.

Behavioral Health – Outpatient
Care for Behavioral Health/Substance Use, including Intensive Day Treatment, Partial Hospitalization Program, Intensive Outpatient Program. 		Authorization for acute inpatient care required. Providers should call UnitedHealthcare at 877.585.9643.
Behavioral Health – Outpatient
Psychological Testing, Neuropsychological Testing		 Authorization is required for psychological or neuropsychological testing. Providers should call UnitedHealthcare at 877.585.9643.
Behavioral Health – Outpatient
Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS).		 Authorization is required. Providers should call UnitedHealthcare at 877.585.9643.
Orthotics and Prosthetics Authorization is required for some orthotics and prosthetics. Providers should call UnitedHealthcare at 877.585.9643.

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 is sometimes required. Providers should call UnitedHealthcare at 877.585.9643.
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
  • CT (computerized axial tomography)
  • MRA (magnetic resonance angiography)
  • MRI (magnetic resonance imaging)
  • NC (nuclear cardiac imaging studies)
  • PET (positron emission tomography).
 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.
Therapy Services: Cardiac Rehabilitation Authorization is required for services after 36 visits. Providers should fax physician progress notes and separate rehab notes with medical records (including cardiac history and recent cardiac events or procedures) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100. At prompt, select option 4.

Therapy Services: Pulmonary Rehabilitation Authorization is required for services after 24 visits. Providers should fax physician progress notes and separate rehab notes with medical records (including medications, pulmonary function tests and O2 levels) to 816.257.3255. For assistance, call Customer Service at 800.821.6136, Ext. 3100.

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 sometimes required. Providers should call UnitedHealthcare at 877.585.9643.