Prior Authorization (PA) Enhancements and Updates

HealthTeam Advantage continues to strive for ease and access to medically necessary care.

Below are detailed changes for 2026. Visit our website for PA lists and forms.

Please be advised that ALL Diabetes & Heart Care (HMO C-SNP) members, when referred for services outside the HealthTeam Advantage network, will always require prior authorization for ANY out-of-network service.

Removed PA Requirements for 2026

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

---

Process Changes

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 have been updated to align with all 2026 changes, and are 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.

Home Health — 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 is not limited to, CT or PET scans, ultrasounds, or MRIs.

---

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.