Beginning on December 1, 2026, UHC will be removing prior authorization for some of its pediatric select CPT codes for children less than 18 years old. This represents a reduction in the amount of prior authorizations that are required, but does not represent a complete removal of all of them.
At this time, UHC has not provided information as to which CPT Codes will be included in this new program; however, each state and plan may have their own specific list of in scope codes.
This new program will apply to all Commercial, Individual Exchange, and Select Community Plan members; whereas Medicare Advantage plans are excluded from participation.
Quick Answer: What Did UnitedHealthcare Announce?
- UHC is eliminating prior authorizations on certain procedure codes for all patients under the age of eighteen, as of December 1st, 2026.
- This removal of prior authorizations applies to Commercial; Individual Exchange; and selected Community Plans.
- Medicare Advantage is excluded from this policy modification.
- UHC has made no public announcement of which CPT codes would be included (as they are expected to vary by State and Plan).
- Continue using your current procedures until you confirm that the patient’s plan; state; and the services have been added to the list.
| Category | Status |
|---|---|
| Effective date | December 1, 2026 |
| Eligible age group | Patients under age 18 |
| Commercial plans | Included |
| Individual Exchange plans | Included |
| Select Community Plans | Included |
| Medicare Advantage | Excluded |
| Complete code list | Not published yet |
| State and plan applicability | Varies |
Why Is UnitedHealthcare Cutting Pediatric Prior Authorization?
UHC stated that at the end of the year it will have removed approximately two thirds of its member authorization (approval) process for all services related to members under the age of eighteen. This would include some types of diagnostic testing, routine surgery, and other pediatric subspecialties including cardiology, neurology, and orthopedics. Additionally, they indicated they still plan to require pre-authorization for those services which may be clinically complex or are being used for non-traditional treatment or as a "specialty" drug.
This was part of regarding removing the authorization for over half of all approvals for services provided to members less than 18 years old. As such, there is no indication within this release of what type(s) of codes were included in this specific roll-out, therefore do not make an assumption as to what types of codes will be included in your December submissions.
When Does the Change Begin?
December 1, 2026. The date of Oct 1st is simply the posting date for the Notice from UHC.
These should be kept as separate dates. Until you have confirmed that this new process affects a certain Patient, Plan & Service, your existing Pediatric Prior Authorization UnitedHealthcare 2026 Workflow will remain intact.
Which Plans Are Affected?
UHC's notice names three included plan groups. It also lists pending and excluded plans.
| Plan group | Status |
|---|---|
| UnitedHealthcare commercial plans | Included |
| Individual Exchange plans | Included |
| Select Community Plans | Included |
| Community Plans in Nebraska, New Jersey, Tennessee | Pending state approval |
| Medicare Advantage plans | Excluded |
| Dual Eligible Special Needs Plans (D-SNP) | Excluded |
| Health Plan of Nevada Medicaid | Excluded |
| UMR plans not following the UMR prior authorization list | Excluded |
NOTICE – The term “select” before Community Plans should alert you to check your state’s community plan individually.
The second issue – UHC has issued a specific notice (and codes) for Community Plans in Arizona, Missouri, New Mexico, New York, Ohio & Washington; this is an entirely separate program. Each notice has its own deadlines.
Which Pediatric Codes Does the Change Affect?
No one outside of UHC has a clue right now. The letter states that prior to the start date of the new program, UHC will publish a list of codes included in the program. Upon commencement of the new program, you will be able to determine if they are covered through use of the Prior Authorization and Notification Tool within the UnitedHealthcare Provider Portal.
Avoid using any unofficial lists including social media, billing company sites, older UHC documentation, or unverified websites. If you have an external medical coder, advise them to wait until the official list is published by UHC.
The letters also indicated that the codes may differ based upon location (state) and type of plan (coverage). It would be best to utilize both service area and whether or not the member is covered as two additional checks.
Why Pediatric Practices Should Prepare Before December 1
How will this affect your daily operations? This change in pediatric prior authorizations by UnitedHealthcare 2026 will not be solely based on patient's age. Each of these three factors (Plan, State, Service) will determine if a doctor's visit requires authorization, and they will make that decision collectively.
This change will impact each department differently:
Front Desk
Verify what plan the patients have enrolled in, their eligibility, and all required authorization at each visit.
Authorization Staff
Be prepared to adjust your work queues as needed but do not remove the steps yet.
Scheduling
If an authorization is missed, it may cancel an imaging or procedure appointment. Check the status of the authorization before scheduling.
Billing/Coding
Ensure all employees are aware that due to this change, not all UHC members will be impacted equally.
What Should Not Change Yet
Keep requesting prior authorization. The announcement of an eventual elimination does not mean they have eliminated it now. Claiming a required authorization is skipped will likely be returned as "denied" which has cost many teams extra time in terms of rework.Do not assume that all pediatric services will be authorization free on December 1. Adhere to current guidelines until you have confirmed with your plan, state, service and member coverage as of December 1
What Should You Track After December 1?
Watch your claims through December. Five signals tell you whether your workflow is right:
- denial of authorizations (claims): identify all claims from UHC stating the service was subject to authorization and submit those to your denial management team to appeal and pattern review.
- misconceptions regarding plans: identify staff assuming every UHC plan has the same rules.
- state variations: compare results across each state in which you bill.
- old lists: identify old lists from work queues, EHR notes, etc. No one updated.
- service(s) still subject to prior authorization: review claims where a service remained under review after reduction.
These checks catch workflow errors. They don't prove the change applies everywhere.
What Should You Do Now?
What should you do first? Count your UHC pediatric volume by plan and state.
Five Steps to Prepare
- Determine how many children are covered under your United Healthcare (UHC) pediatric volume and count both patient numbers and services in each of the plans categories by state.
- Segment Your Plans. The commercial, exchange, community plan and Medicare Advantage patients require separate ways of doing business; there is no single path that will be applicable to all UHC patients.
- Carefully check the official code list. Review what has been announced by UHC regarding codes, as well as the Prior Authorization & Notification Tool. Do NOT rely on unofficial lists.
- Move tasks from a "work queue" only AFTER Verification. Remove a task from a work queue when you have confirmed the Service was provided and the patient's plan type.
- Review your December Claims. Identify Denied Authorizations, Incorrect Assumptions, State Differences and Outdated Rules. If you perform an annual or monthly review of your healthcare revenue cycle management services add UHC Pediatric Claims to your review.
Quick Checklist
- Review UHCS communication to confirm that the new codes are being used (effective Dec 1/2016)
- Use a coding matrix to segment patients with United Health Care plans into different categories of care (i.e., commercial plans, Medicare Advantage etc.)
- Verify specific state rules and regulations prior to making changes to your company’s policies or procedures
- Identify when UHC will provide the updated code list
- Verify all services via United Health Care's online provider portal (or other resource provided by UHC), before updating internal systems or workflows
- Only make updates to your internal workflow once you have verified all information
- Train your staff on the authorization process and how it relates to the new coding system
- Track denials related to this new policy through at least January; review and update as necessary
Frequently Asked Questions
No - only certain pediatric services will have no prior authorization requirements - only those that are included on an eligible plan.
Yes, UHC has listed Medicare Advantage plans as exempt from this program.
No, the new "in scope" codes are expected to be announced at least 30 days prior to the implementation of this program by united health care. Do not infer any codes based on this information.
Don't count on it. UHC says the codes vary by state and plan.
No. Follow current requirements until the effective date passes and you've verified the plan, state, and service.
UnitedHealthcare’s pediatric prior authorization 2026 rollout is built around the idea of verifying first and adjusting second. It helps protect your clean claims by avoiding staff to work based on a “guess” in their workflow. Human Medical Billing supports practices with their pediatric authorization process, including claim verification and denial follow up. We can help support your practice's Pediatric Authorization Workflow as well as Claim Accuracy and Denial Follow Up prior to December 1.
Contact Us to review how your team currently manages UHC plans. Bring your plan mix, State List, and current UHC authorization workflow. We will review your workflow with you and identify areas where an assumption may result in denied claims.
Contact Human Medical Billing to schedule a compliance readiness review or learn more about our end-to-end billing and regulatory support services.
