Prior Authorization (PA) Enhancements and Updates

HealthTeam Advantage continues to strive for ease and access to medically necessary care. Below are detailed changes coming for 2026.

Removed PA Requirements

• Sleep Studies. Beginning in 2026, the following CPT codes no longer require prior authorization: 95782, 95783, 95803, 95805, 95807, 95808, 95810, 95811.
• Diabetic Shoes and Inserts. Beginning in 2026, the following HCPCS codes no longer require prior authorization: A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5512, A5513, and A5514.
• DME Supplies. Beginning in 2026, no DME supplies (any HCPCS A Codes) will require prior authorization. Please note: CMS quantity limits still apply.
• Continuous Passive Motion Device (CMP). Beginning in 2026, HCPC E0935 (knee) will no longer require prior authorization.

Process Changes

In order to be compliant with the new 2026 CMS Turnaround Time (TAT) from 14 days to 7 days for prior to service standard (PTS) requests:

• To prevent delays in care or lack of clinical information denials, please submit all applicable clinical documentation with a completed prior authorization form.
• HealthTeam Advantage 2026 prior authorization forms will be updated to align with all 2026 changes, and will be available here for download.

Home Health

What IS changing:

• HealthTeam Advantage will begin accepting Resumption of Care following hospital admissions, effective 1/1/2026.
• HealthTeam Advantage will increase the number of visits administratively approved following an inpatient or observation hospital stay. Previous administratively approved numbers were 7 RN, combination of 6 PT/OT/SP, 1 SW, and 9 HHA.
• For Community/Post-Acute referrals (request type #3), the evaluation visit will no longer need to be submitted first. However, the request must still be submitted within 7 days of the start of care.

What IS NOT changing:

• The 7-day grace period will remain in place for the start of care and now resumption of care.
• All requests should include a completed prior authorization form, physician and/or hospital order, and supporting clinical documentation.
• There will be no grace period on requests for additional visits to an existing authorization.
• Existing visit requests will continue to be added to the applicable authorization based on the certification period.

  • Request Types:

    • Request Type 1: Resumption of Care (ROC) will be accepted effective 1/1/2026.
    • Request Type 2: New Request following an IP/OBS admission. This means there is no previous Home Health authorization on file, nor a Resumption of Care.
      • 10 RN or LPN combo
      • 10 PT or PTA combo
      • 10 OT or OTA combo
      • 6 ST
      • 3 CSW
      • 10 Home Health aide
    • Request Type 3: Community Referral (Post SNF discharge or Post PCP visit).
      • 6 RN visits (includes evaluation visit)
      • 6 PT visits (includes evaluation visit)
      • 6 OT visits (includes evaluation visit)
      • 6 ST visits (includes evaluation visit)
      • 6 Home Health aide (includes evaluation visit)
      • 3 CSW (includes evaluation visit)
    • Request Type 4: Recertifications
      • Please submit all clinical documentation with physician’s order.
      • No 7-day grace period for recertification request
• Turnaround Time (TAT):
  •  7 days for all Standard requests
  • 72 hours for all Expedited requests

Diagnostic Imaging

Please do not submit prior authorization for any diagnostic imaging. HealthTeam Advantage does not require prior authorization on any 7 series CPT codes for radiology or radiology services. This includes, but it is not limited to, CT or PET scans, ultrasounds, or MRIs.

Please be advised that all Diabetes & Heart Care (HMO C-SNP) members, when referred for any services outside HealthTeam Advantage’s network, will always require a prior authorization on any out-of-network service.

How to Contact Us

Our Utilization Management team can be reached at 844-806-8217, option 3, Monday through Friday from 8 am to 5 pm. After hours, please call 336-207-2095.

If you have questions, please reach out to your Provider Concierge team at 844-806-8217, option 5.