Medicare-Medicaid Pre-Auth
All attempts are made to provide the most current information on the Pre-Auth Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts and correct coding and billing practices. For specific details, please refer to the Medicare-Medicaid 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.
All out-of-network requests require prior authorization except emergency care, out-of-area urgent care or out-of-area dialysis.
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 requested for pain management, dental surgery or services in the office rendered by a non-participating provider? |
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.