Prior Authorization Update 02/01/2026

Date: 12/30/25

Heritage Health (Medicaid):

Important Prior Authorization Updates
(Effective Feb. 1, 2026)

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Nebraska Total Care wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.

Code change details can be found below. These changes may include:

• Removing PA requirements based on criticality of review and clinical need.
• Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.

If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Relations representative.

 

Prior Authorization Updates (Effective Feb. 1, 2026)

Service Category	PA Rule	Services	Procedure codes
Behavioral Health	PA Required	Substance Abuse Treatment	H0004, H2022
		Therapy	H2019
Cardiovascular	PA Required	Heart Surgery	93656
DME Services	PA Required	Orthotic and Prosthetic	L1833
Drug Codes	PA Required	Injections	J1437, J1944, Q4081
		Medications	J2426, Q0138, Q0139
	No PA Required	Medications	J3489
Genetic Analysis	PA Required
	No PA Required	Genetic Testing	81331
Laboratory	PA Required	Urinalysis	G0480, G0481
	No PA Required	Pathology	81270
Other Medical Services	PA Required	Other Services	T1025
	No PA Required	Other Services	97760, 97763
Physical Medicine	PA Required	Orthotic and Prosthetic	Q4101, Q4121, Q4186, Q4195, Q4196
Surgery Procedures	PA Required	Cardiovascular System	33249, 33285, 92928
		Digestive System	49329, 49505, 49591, 49593, 49650
		Female Genitalia	58662
		Integumentary System	19301, 19357
		Male Genitalia	54360
		Nervous System	64999
	No PA Required	Female Genitalia	58940
		Vascular	36471, 36479
		Wound Care	13100, 13101, 13102, 13151, 13152
Transportation Services	PA Required	Medical Transportation	A0428, A0431, A0436