Every payer publishes prior authorization (PA) policies. None of them format them the same way, update them on the same schedule, or care about the same clinical evidence. The result: practices submit the same documentation to every payer and get denied by half of them for documentation gaps that were entirely avoidable.
This guide covers the top 10 payers — UnitedHealthcare, Anthem, Aetna, Cigna, Humana, Blue Cross Blue Shield (BCBS), Medicare Advantage, Medicaid, Centene, and Molina — with specifics on what each one actually requires in 2026. It also covers the CPT codes most likely to trigger PA requirements and the universal documentation checklist that applies across all payers.
2026 mandate note: CMS now requires Medicare Advantage and Medicaid payers to issue standard PA decisions within 72 hours (urgent) and 7 days (non-urgent), and to provide specific denial reason codes. This creates an audit trail — use it when appealing. See our CMS 2026 PA Mandate guide for full details.
Why Payer Requirements Differ So Much
PA requirements aren't arbitrary — they're built around each payer's clinical policy committees, formulary structures, and network agreements. UnitedHealthcare processes over 70 million PA requests per year; their requirements reflect actuarial risk models tuned at scale. A small regional BCBS plan has entirely different cost pressures and may require different supporting documentation for the same procedure.
The practical implication: you cannot submit identical documentation packets to every payer and expect consistent results. Each payer weights clinical evidence differently. Practices that tailor documentation per payer report denial rates 30–40% lower than those using generic submissions.
Top Payers: Requirements, Timelines, and What They're Actually Looking For
- Provider NPI, Tax ID, and rendering provider credentials
- Clinical notes from the last 60–90 days showing diagnosis history
- Functional status documentation (objective measures preferred — ADL limitations, pain scales, range of motion)
- Evidence of conservative therapy failure for musculoskeletal and behavioral health requests
- ICD-10 codes with specificity to 5th or 6th character level
- CPT code with site of service modifier (22 for increased complexity, 51 for multiple procedures)
UHC uses InterQual criteria for most medical/surgical requests. Behavioral health uses proprietary criteria. Submit through UHC Provider Portal or via phone for urgent requests.
- Completed PA request form (state-specific forms vary — verify current version)
- Clinical summary with onset date, treatment history, and current functional status
- Attending physician attestation for specialty referrals
- Peer-reviewed literature or clinical guidelines for experimental/investigational procedures
- Prior treatment records including dates, providers, and response
- Lab results, imaging reports, or diagnostic workup within policy timeframe
Anthem uses Milliman Care Guidelines (MCG) in most states. Behavioral health and specialty drug PAs route to separate review teams. Submit via Availity portal.
- Member ID, group number, and plan type (commercial vs. MA vs. Medicaid)
- Clinical indication letter — Aetna requires a written summary, not just attached notes
- For musculoskeletal: 6-week conservative therapy documentation before any imaging or interventional
- For specialty drugs: step therapy compliance documentation, formulary alternatives tried and failed
- For behavioral health: standardized functional assessment (PHQ-9, GAD-7, Columbia Suicide Severity scale)
- Treating physician's clinical rationale for selected CPT code over alternatives
Aetna uses proprietary clinical criteria alongside InterQual. Step therapy requirements are aggressive for specialty pharmacy. Submit via Aetna provider portal or NaviMedix fax.
- Rendering provider credentials and facility NPI
- Diagnosis-specific clinical criteria documentation — Cigna publishes coverage policies online; match your clinical summary to listed criteria
- For imaging: referencing physician attestation that results will change clinical management
- For surgery: failed conservative management with dates and specific treatments tried
- For behavioral health inpatient: Columbia Suicide Severity Rating Scale or equivalent
- Place of service justification if not standard outpatient
Cigna's coverage policy library is searchable at cigna.com. Match your clinical documentation to their stated criteria explicitly — vague summaries get denied. Submit via Evicore (Cigna's external review vendor) for many specialty and radiology codes.
- Humana authorization request form (HumanaOne or provider portal submission)
- Clinical documentation from the last 30 days for acute conditions; up to 6 months for chronic
- For MA members: CMS documentation requirements — Humana MA PAs must comply with CMS 2026 decision timelines and denial reason codes
- Treating physician's name, credentials, and direct contact number for peer-to-peer
- Expected length of treatment or episode duration
- For post-acute: discharge plan, functional goals, and therapy frequency
Humana is heavily Medicare Advantage — CMS 2026 timelines apply to most Humana PAs. Peer-to-peer requests must go to the reviewing physician, not a nurse reviewer. Submit via Availity or HumanaOne portal.
- Plan-specific form — BCBS has 36 independent plans with separate PA requirements. BCBS Alabama is not BCBS California. Verify the specific plan before submitting.
- BCBS Federal Employee Program (FEP) follows separate clinical criteria from commercial plans
- Most plans use Blue Distinction Center criteria for specialty procedures (bariatric, cardiac, cancer)
- Clinical documentation requirements generally align with MCG criteria
- Network provider documentation — out-of-network PAs require additional justification
The most common BCBS mistake: submitting to the wrong plan entity. Verify the patient's BCBS plan ID prefix — it identifies the administering plan. BCBS FEP (prefix R) has entirely different PA requirements.
- CMS requires MA plans to issue denial codes that explain the specific clinical criteria not met — use these codes when appealing
- Original Medicare coverage rules apply — if Medicare would cover it without PA, an MA plan cannot require PA for that service (2024 rule)
- Attending physician's attestation that the requested service is medically necessary per CMS LCD/NCD coverage determinations
- For post-acute care: functional assessment, discharge readiness, and 3-midnight rule documentation if applicable
- Beneficiary continuity of care documentation if switching from non-participating provider
MA is the highest-volume PA category for most practices. CMS 2026 rules mean MA payers must now respond within strict timelines and provide actionable denial codes. If an MA payer misses the 72-hour urgent deadline, document it — that's grounds for a clean appeal.
- State Medicaid program portal or state-specific PA form — requirements vary significantly by state
- Documentation of medical necessity per state Medicaid coverage criteria (not commercial criteria)
- For managed Medicaid (Centene, Molina, etc.): follow the managed care organization's requirements, not the state's fee-for-service rules
- Income and eligibility documentation may be required for retroactive authorization
- For behavioral health and long-term care: state-specific assessment tools and functional criteria
Medicaid PA requirements are state-administered and change frequently. Managed Medicaid plans (Centene WellCare, Molina, Meridian) add their own layer of requirements on top of state rules. Verify current requirements quarterly.
CPT Codes That Most Commonly Require Prior Authorization in 2026
Not every procedure needs a PA — and submitting unnecessary PAs wastes time. The following table covers the CPT codes that trigger PA requirements across the most payers. Always verify against the specific payer and patient's plan before submitting.
| CPT Code | Procedure | PA Required By | Key Documentation |
|---|---|---|---|
| 27447 | Total knee arthroplasty | All major commercial + MA | X-ray, failed conservative tx, BMI, functional status |
| 27130 | Total hip arthroplasty | All major commercial + MA | Imaging, conservative therapy failure, functional limits |
| 70553 | MRI brain w/ contrast | UHC, Aetna, Cigna, Humana | Clinical indication, prior imaging, neurological exam |
| 72148 | MRI lumbar spine w/o contrast | UHC, Aetna, Cigna, Anthem | 6-week conservative tx, red flag symptoms, functional assessment |
| 43239 | EGD with biopsy | UHC, Aetna, Cigna | Symptom duration, failed PPI trial, clinical indication |
| 43770 | Laparoscopic gastric band | All commercial (some exclude entirely) | BMI criteria, 6-month supervised program, psych eval |
| 90837 | Psychotherapy, 60 min | UHC, Humana, Cigna, some BCBS | Diagnosis, treatment plan, medical necessity, session frequency |
| 96132 | Neuropsychological testing | UHC, Aetna, Anthem, Cigna | Referral, specific diagnostic questions, prior workup |
| 99215 | Office visit, high complexity | Some Medicaid MA plans | Documented complexity, MDM or time-based coding |
| J0135 | Adalimumab (Humira) injection | All commercial, MA, Medicaid | Step therapy (csDMARD failure), diagnosis confirmation, monitoring labs |
| J2357 | Omalizumab (Xolair) injection | All commercial + MA | Severe persistent asthma dx, IgE level, weight, failed controller therapy |
| 99291 | Critical care, first 30–74 min | Most commercial (concurrent review) | Concurrent authorization; document real-time clinical status |
Radiology and imaging tip: Most imaging PAs now route through radiology benefit managers (RBMs) — Evicore (Cigna, some BCBS, Centene), AIM Specialty Health (UHC), NIA Magellan (Humana, some Medicaid). Your PA request goes to the RBM portal, not the payer portal. Using the wrong portal is one of the most common causes of delayed authorizations.
The Universal PA Documentation Checklist
Every payer has specific requirements, but these elements appear on almost every PA checklist across all payers. Use this as your baseline before adding payer-specific documentation.
- Member/patient demographics: Full name, date of birth, member ID, and plan name exactly as they appear on the insurance card
- Rendering and requesting provider: NPI (Type 1 for individual, Type 2 for group), Tax ID, address, phone, and fax for both if different
- Procedure identification: CPT code(s) with applicable modifiers, ICD-10 diagnosis code(s) to maximum specificity, proposed date of service
- Medical necessity narrative: Written clinical justification — not just attached notes, but a clear statement connecting the diagnosis to the requested procedure and why alternatives are insufficient
- Clinical supporting documentation: Office notes, lab results, imaging reports, specialist consultations — dated within the payer's required timeframe (typically 60–90 days for acute, 6 months for chronic)
- Treatment history: Prior treatments attempted, dates, doses, and response — especially conservative therapy for musculoskeletal and medication alternatives for specialty pharmacy
- Place of service and facility: Site of service code, facility NPI and address if different from requesting provider
- Urgency designation: Standard vs. expedited/urgent — if urgent, document the clinical basis for urgency (delayed care would cause serious harm)
Know Your Approval Likelihood Before You Submit
Upload your PA to Prelude and get an AI analysis of your documentation gaps — payer-specific, before you submit.
Check PA Approval Likelihood — Free →Payer-Specific Submission Portals and Phone Numbers
Submitting to the right portal is half the battle. Here are the primary submission channels for each major payer:
| Payer | Primary Portal | Imaging/Specialty Vendor |
|---|---|---|
| UnitedHealthcare | UHC Provider Portal (myuhc.com/providers) | AIM Specialty Health (radiology, cardiology, specialty drugs) |
| Anthem / Elevance | Availity Essentials | AIM Specialty Health (in most states) |
| Aetna | Aetna provider portal (aetna.com/providers) | Evicore (radiology); Omnicare (specialty drugs) |
| Cigna | Cigna for Health Professionals (cignaforhp.com) | Evicore (most specialty, radiology, behavioral health) |
| Humana | Availity or HumanaOne Provider Portal | Evicore (radiology, PT/OT); specialty drugs via Humana Pharmacy |
| BCBS (varies) | Availity or plan-specific portal | AIM or Evicore depending on plan |
| Medicare Advantage | Plan-specific portal (varies by MA plan) | Same as parent commercial plan |
| Medicaid | State Medicaid portal (varies by state) | Managed care plan portal if managed Medicaid |
What Happens After You Submit: Decision Timelines and Next Steps
Knowing when to follow up is as important as what you submit. Missing a payer's decision window means the PA may lapse without notification — and the claim gets denied for lack of authorization.
Standard timelines across all major payers in 2026 (CMS-mandated for MA; commercial varies):
- Standard (non-urgent) decisions: 3–14 calendar days depending on payer and plan type
- Urgent/expedited decisions: 72 hours (CMS-mandated for MA; most commercial plans match)
- Concurrent review (inpatient): 24–48 hours for each authorization extension
- Pharmacy step therapy PAs: 72 hours for urgent; 3 business days standard
If you haven't received a decision by the end of the payer's stated timeline, call the provider services line and request a status update. Document the date, time, representative name, and call reference number. This creates a paper trail for appeals if the authorization is subsequently denied after the deadline.
If the decision is a denial, you have the right to appeal. 75–85% of PA denials that are appealed with complete documentation are overturned. See our step-by-step PA denial appeal guide for the exact process.
Reducing Denials Before They Happen
The most effective PA strategy is front-loading documentation before initial submission. Practices that receive the lowest denial rates share three habits:
- They match documentation to the payer's stated clinical criteria — not generic medical necessity language. If UHC uses InterQual, the clinical note should address InterQual criteria explicitly.
- They submit to the right entity — payer portal vs. RBM portal vs. specialty pharmacy vendor. Wrong submission channel causes delays that look like denials.
- They use AI pre-submission review to identify documentation gaps before submission. Practices using AI PA review report first-pass approval rates 40–60% higher than those without.
Prelude's AI analyzes your PA documentation against payer-specific requirements and flags exactly what's missing before you submit — so you're not learning about the gap from a denial letter three weeks later.
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