Authorizations/Precertifications HDHP, Standard and High Option members
Important note: The authorization information on this page is for GEHA's HDHP, Standard, and High plan members. For other medical plans, visit Authorizations/Precertifications for Elevate and Elevate Plus members.
General information
- Authorization requirement: GEHA, like other federal health plans, requires providers to obtain authorization before some services and procedures are performed.
- Reference: More information can be found in the GEHA plan brochure. For quick reference, see the GEHA member's ID card.
- Clinical guidelines: The sources of our clinical guidelines can be found on our Sources of Utilization Management Criteria (PDF).
- Primary payer: If Medicare or another group health insurance policy is the primary payer for these services, you do not need to obtain authorization.
Emergency admissions
If 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:
- Action required: 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.
- Responsibility: Although your physician or hospital will precertify your stay, it is your responsibility to ensure that precertification is complete.
- Failure to precertify: Failure to precertify inpatient stays could result in a benefits reduction.
- International admissions: It is not necessary to precertify hospital admissions outside the United States. For more details on your GEHA coverage when traveling, click Outside the United States.
Contact information
- Benefits and eligibility: Call GEHA's Customer Care department at 1-800-821-6136.
- Prior authorization: Refer to the back of the patient's ID card under the heading Prior Authorization for the appropriate contact information and submission.
Services/Surgeries requiring authorization
Authorization is required for all services addressed below.
Please scroll to the bottom of the page for details regarding obtaining prior authorization on the following services:
- Applied Behavioral Analysis (ABA) therapy
- Cancer treatment
- Fertility procedures and medications
- Prescription drugs
- Specialty prescription drugs
- Radiology
- Transplants
Surgeries/Procedures Requiring Authorization | |
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To obtain authorization on the following services, providers should contact UnitedHealthcare at 1-877-585-9643. | |
Category | Procedures |
Arthroplasty | Including revisions to a prior arthroplasty |
Back and spinal procedures | Discectomy/fusion, implanted infusion pumps and insertion procedures for pain management, spinal cord stimulators |
Bariatric surgery | Bariatric and metabolic surgical procedures (obesity surgery) |
Bone growth stimulators | Bone growth stimulators |
Breast and chest surgeries | Breast reconstruction (non-cancer), gynecomastia treatment (cosmetic), mammoplasty reduction |
Cardiac and vascular procedures | Ablative treatment of venous insufficiency including sclerotherapy and microphlebectomy, implantable cardiac monitoring, nuclear medicine studies including nuclear cardiology, transcatheter arrhythmia ablation, transcatheter aortic and pulmonary valve repair or replacement |
Cartilage implants | Autologous Cultured Chondrocytes (ACI), osteochondral grafting |
Cellular and gene therapy | Cellular and gene therapy |
Cochlear implants | Cochlear and auditory implants and procedures |
Durable medical equipment | Durable medical equipment (DME) |
Experimental/Investigational | Surgery or treatment, including clinical trials |
Genetic testing | Genetic testing |
Hyperhidrosis | Surgical treatment (requires failure of alternative therapies) |
Hysterectomy | Except for diagnosis of cancer |
Medical/Surgical facilities | Acute inpatient, Long-Term Acute Care (LTAC), Acute Rehabilitation Facility (ARF), Skilled Nursing Facility (SNF) |
Mental health facilities and programs | Acute inpatient, Sub-acute inpatient, Residential Treatment Centers (RTC), Intensive Outpatient Programs (IOP), Partial Hospitalization Programs (PHP) |
MR-guided Focused Ultrasound | MR-guided Focused Ultrasound (MRgFUS) |
Non-Emergency air ambulance | Non-emergency air ambulance transportation |
Orthognathic surgery | Jaw surgery, including TMJ |
Orthopedic devices | Orthopedic devices and prosthetic devices |
Psychological and neuropsychological testing | Exceeding 8 hours/year |
Reconstructive or potential cosmetic procedures | Abdominoplasty, panniculectomy, lipectomy, eyelid surgery, brow lift, rhinoplasty, scar revisions, surgical correction of congenital anomalies |
Sleep studies (in-lab) | Attended or performed in a health care facility (home sleep studies do not require preauthorization) |
Speech devices | Speech-generating devices |
Surgical treatment of airway obstructions, including for sleep apnea | Uvulopalatopharyngoplasty (UPPP), hyoid myotomy and suspension, Functional Endoscopic Sinus Surgery (FESS), sinuplasty, correction of choanal atresia and intranasal synechia |
Surgical treatment of gender dysphoria | Surgical treatment of gender dysphoria |
Wound care (outpatient) | Advanced wound therapy |
Specific instructions for authorization on the following services:
Applied Behavior Analysis (ABA) therapy |
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Cancer treatment |
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Fertility procedures and medications |
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Prescription drugs |
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Specialty prescription drugs |
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Radiology |
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Transplants |
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