Authorizations/Precertifications for HDHP, Standard and High Option members

Note: The authorization information on this page is for GEHA's HDHP, Standard and High Option plan members. If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, 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.

Surgeries/Procedures Requiring Authorization
Back – Spinal fusions/Multi-level spinal surgeries/Artificial disc replacements Authorization is required. Providers should download a Spinal Surgery Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For assistance, call GEHA at 800.821.6136, ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus 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.

Breast Procedures

Breast Reconstruction (except reconstruction for diagnosis of breast cancer)
Authorization is required. Providers should download a Breast Reduction Authorization form, complete it and fax it (along with supporting documents ) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.

Gynecomastia: Reduction (unilateral/bilateral)
For other cosmetic procedures, providers should download a Experimental/Investigational and Cosmetic Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. Do not fax images. Email images to caremanagementsurgery@geha.com. For further assistance with images, call GEHA at 800.821.6136, Ext. 3100.

Mammoplasty: Reduction (unilateral/bilateral)
Authorization is required. Providers should download a Breast Reduction Authorization form, complete it and fax it (along with supporting document(s) – including number of grams per breast to be removed) to 816.257.3255. Do not fax images. For assistance with images, call GEHA at 800.821.6136, Ext 3100.

Mastectomy performed prophylactically
Authorization is required. Providers should fax medical records (including CPT codes) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.

Reconstructive Surgery

  • Blepharoplasty or other types of eyelid surgeries, browlift
  • Liposuction and scar revisions
Authorization is required.

For blepharoplasty or other types of eyelid surgeries, providers should download a Reconstructive Eyelid Surgery Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. Do not fax images. Email images to caremanagementsurgery@geha.com. For further assistance with images, call GEHA at 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
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 should fax medical records (including CPT codes and supporting documents) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.

Gender Reassignment Surgery Authorization is required. Providers should download a Gender Reassignment Surgery Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.

Osteochondral grafting of articular lesions including autologous chondrocyte transplants Authorization is required. Providers should download a Osteochondral Authorization (including Grafting and Autologous Cultured Chondrocyte Implantation) form, complete it and fax it (along with supporting documents) to to 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.

Bariatric Surgeries
(Weight-loss surgery)

Authorization is required. Providers should download a Bariatric Authorization form, complete and fax (along with supporting documents) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus 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 fax authorization requests (along with supporting documents) to 816.257.3515 or 816.257.3255. For assistance, call 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.

Panniculectomy/Abdominoplasty/Lipectomy Authorization is required. Providers should download a Panniculectomy/Abdominoplasty Authorization form, complete it and fax it [along with supporting document(s)] to 816.257.3255. Do not fax images. Email images to caremanagementsurgery@geha.com. For further assistance with images, call GEHA at 800.821.6136, Ext 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.

Rhinoplasty/Sinus surgery Authorization is required. Providers should download and submit a Nasal Surgeries Authorization form (along with supporting documents).

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus 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. For In-Lab Sleep Study services, download an In-Lab Sleep Study Authorization form, complete the form and fax it (along with requested documents) to 816.257.4516. Be sure to check one of the appropriate listed conditions and provide supporting documentation. Do not fax images. Email images to caremanagementsurgery@geha.com. For further help with images, please contact GEHA's Call Center at 800.821.6136.
  • If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus 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 fax medical records (including tried and failed treatments and CPT codes) to 816.257.3255. For assistance, call 800.821.6136, ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
Uvulopalatopharyngoplasty (UPP) Authorization is required. Providers should fax medical records (including tried and failed treatments and CPT codes) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
Vein Surgeries (leg) The following require authorization:
  • Ablation therapy
  • Stab phlebectomy
  • Other vein procedures
Providers should download a Vein Surgeries Authorization form, complete it and fax it (along with supporting documents) to 816.257.3255. For assistance, call GEHA at 800.821.6136, ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus 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.

Follow this link to complete an online ABA assessment form.
Speech-Generating Devices Authorization is required. Providers should complete the Durable Medical Equipment (DME) Authorization form, and fax it to 816.257.3255 or 816.257.3515. For assistance, call 800.821.6136, ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
Cancer Treatment – non-surgical Authorization is required. To obtain preauthorization, providers should log in to oncologyanalytics.com 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 oncologyanalytics.com 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.

Before January 1, 2021: Providers are to continue to send non-surgical cancer treatment plans for HDHP, Standard and High Option Plans to Eviti at eviti.com or call 888.482.8057.

Authorizations previously issued by Eviti before January 2021 will be effective until the authorization expiration date – there is no need to resubmit the existing treatment plan to Oncology Analytics for authorization.
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 Authorization form, complete it and fax it to 816.257.3255. For assistance, 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 download a Durable Medical Equipment (DME) Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For assistance, call 800.821.6136, Ext. 3100.

For cranial helmets, legible pictures with supporting documentation, medical records demonstrating cranial dimensions, prior therapies and response to such therapies can be mailed to GEHA Medical Management at PO Box 21542, Eagan, MN 55121.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.

These supplies and equipment do not require authorization:
  • Walkers: E0130-E0149
  • Platform attachment for walkers: E0153-E0159
  • Canes: E0100-E0105
  • Crutches: E0110-E0118
  • Compression stockings: A6530-A6549
  • Ostomy supplies: A4361-A4415
  • External urinary catheters: A4356-A4358
  • Incontinence catheters: A4310-A4335
Genetic Testing Authorization is required. Online authorization from evicore.com is required. Before starting the online authorization process, providers should download the Quick Reference Guide to Genetic Testing (PDF) and then proceed to evicore.com. For assistance, call 866.879.8317.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus 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 is required. Providers/hospitals should call Conifer Health Solutions at 800.242.1025; Fax: 866.315.6314. 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. Please contact Customer Care for surgical procedure authorization at 800.821.6136.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
Behavioral Health – Outpatient
Psychological Testing, Neuropsychological Testing
Authorization is required for psychological or neuropsychological testing only if more than 6 hours of testing will be done. Providers should download a Psychological or Neuropsychological Testing Authorization form, complete it and fax it to 816.257.3515 or 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
Behavioral Health – Outpatient
Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS).
Authorization is required. Providers should download a TMS/ECT Authorization form, complete it and fax it to 816.257.3515 or 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
Orthotics and Prosthetics Authorization is required for some orthotics and prosthetics.

Orthotics: Call GEHA at 800.821.6136, Ext. 3100.

Prosthetics: Providers should download a Prosthetic Device Authorization form, complete and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For assistance, call 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus 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 required for pain management. Providers should download a Pain Management Authorization form, complete it and fax it (along with supporting documents) to 816.257.3515 or 816.257.3255. For assistance, call GEHA at 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus 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.

About US Imaging: After you obtain eviCore healthcare's authorization, you might be contacted by US Imaging, which is an optional scheduling program for GEHA members. However, you always have the option of going to the facility of your choice. You can contact US Imaging by phone at 877.904.3877 or online at usimagingnetwork.com

US Imaging does not schedule services for members with Medicare A& B primary or Medicare Part B only.

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 should call OrthoNet at 877.304.4419; fax: 877.304.4409. For assistance, call 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
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. Please call GEHA at 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
Cognitive Rehabilitation

 Authorization is not required for Cognitive Rehabilitation, effective Jan. 1, 2021.

For services before Jan. 1, 2021, authorization is required. Providers should download a Cognitive Rehabilitation Authorization form, complete and fax it (along with supporting documents) to 800.821.3136 or 816.257.3255. For assistance, call 800.821.6136, Ext. 3100.

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 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.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
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.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.
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 should download a Wound Care Authorization form, complete and fax it (along with supporting documents, including tried and failed treatment, history, wound measurements and treatment plan) to 816.257.3255. For assistance, call 800.821.6136, Ext. 3100.

If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington D.C., West Virginia or Wisconsin, do not complete an authorization form. Instead, contact UnitedHealthcare Choice Plus at 877.585.9643.