Medicare Pre-Auth
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 Medicare Advantage provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
The following services need to be verified by Evolent.
Complex imaging, MRA, MRI, PET, and CT scan
Musculoskeletal services
Pain Management
Therapy- PT/OT/ST *Note - excludes services in the home setting.
Oncology/supportive drugs are handled by New Century Health.
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network
Are services being performed in the Emergency Department or Urgent Care Center, or are the services for dialysis or hospice?
| Types of Services | YES | NO |
|---|---|---|
| IS THE MEMBER BEING ADMITTED TO AN INPATIENT FACILITY? | ||
| ARE ANESTHESIA SERVICES BEING RENDERED FOR PAIN MANAGEMENT, DENTAL SURGERY, OR SERVICES IN THE OFFICE RENDERD BY A NON-PARTICIPATING PROVIDER? | ||
| IS THE MEMBER RECEIVING GENDER REASSIGMENT SERVICES? | ||
| IS THIS AN HMO OUT-OF-NETWORK SERVICE REQUEST? |