Ambetter Pre-Auth
All attempts are made to provide the most current information on the Pre-Auth Needed Tool. A prior authorization is not a guarantee of payment. Payment may be denied in accordance with Plan’s policies and procedures and applicable law. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
The following services (identifiable by procedure code search) need to be verified by EvolentExternal Link: Complex Imaging, MRA, MRI, PET, and CT scans; Left Heart Catheterization & Implantable services; Speech, Occupational and Physical Therapy services (Chiropractor specialty providers excluded and follow authorization requirements with the health plan). Pain Management, Spinal Cord Stimulators and Musculoskeletal services for the spine, shoulder, hip, and knee.
Behavioral Health services need to be verified by Ambetter from Absolute Total Care
Oncology/supportive drugs for members age 18 and older need to be verified by New Century HealthExternal Link
Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix; Fax 877-250-5290
Services provided by Out-of-Network providers are not covered by the plan. Join Our Network.
NOTE: Services related to an authorization denial will result in denial of all associated claims.
Are services being performed in the Emergency Department, or for Emergent Transportation?
| Types of Services | YES | NO |
|---|---|---|
| Are services being performed or ordered by a non-participating provider? | ||
| Is the member being admitted to an inpatient facility? | ||
| Are anesthesia services being rendered for pain management or dental surgeries? | ||
| Are services being rendered by a chiropractor? | ||
| Is the member receiving hospice services? | ||
| Is the member receiving gender reassignment services? | ||
| Are services being rendered in the home excluding sleep studies, DME, medical equipment supplies, orthotics and prosthetics? |