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Medicaid Pre-Auth

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DISCLAIMER:

All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the Medicaid Provider Manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

Prior authorization for medications will NOT be accepted through the web portal.

For Pharmacy prior authorization requests, please visit our pharmacy page.

 

  • Vision Services need to be verified by Envolve Vision.
  • Hospice requests should be submitted to SC DHHS Medicaid Fee for Service program.
  • Oncology/supportive drugs for members age 18 and older need to be verified by New Century Health.
  • Dental services for members under 21 need to be verified by SCDHHS through the EPSDT program.
  • Complex imaging, MRA, MRI, PET, CT scans, Interventional Pain Management and Musculoskeletal Services need to be verified by NIA. 
  • Outpatient rehabilitative and habilitative physical medicine services PT, OT, and Speech need to be verified by NIA. *Note - excludes services in the home setting.

 

For non-participating providers, Join Our Network.

Prior authorization is required for all non-emergent services provided by non-contracted providers. 

 

Are Services being performed in the Emergency Department (other than observation), or Urgent Care Center, or Public Health or Public Welfare Agency, or Family Planning services billed with contraceptive management diagnosis?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are services, other than DME, orthotics, prosthetics, and supplies, being rendered in the home?
Are services being rendered by a podiatrist?
Are anesthesia services being rendered for pain management?

If an authorization is needed, you can log in to your account to submit one online or fill out the appropriate fax form on the Provider Manuals and Forms page.