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Pre-Auth Check | Ambetter from MHS Indiana

 

Pre-Auth Needed?

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DISCLAIMER:

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.  Claim payment depends on member eligibility, covered benefits, provider contracts, correct coding and billing practices. 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.

Vision services need to be verified by Centene Vision ServicesExternal Link.

Dental services need to be verified by Centene Dental ServicesExternal Link.

The following services need to be verified by EvolentExternal Link: Speech, occupational & physical therapy; Complex Imaging, MRA, MRI, PET & CT scans; Musculoskeletal services for shoulder, hip, spine and knee surgery; Pain management and spinal cord stimulator services; Chiropractic specialty providers are NOT managed by Evolent.  

Cardiac services need to be verified by TurningPoint.External Link

Behavioral Health/Substance Abuse need to be verified by Indiana Managed Health.

Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix ; Fax 877-250-5290.


Ambetter Health Solutions PPO members receive benefit coverage for In and Out-of-Network providers.  For all other Ambetter EPO/HMO members, services provided by Out-of-Network providers are not covered by the plan, without prior authorization. Join Our Network

 

Are Services being performed in the Emergency Department?

Types of Services YES NO
For NON-PPO Members only: Are the services being performed or ordered by a non-participating provider (professionals/facilities)?
Is the member being admitted to an inpatient facility?
Are anesthesia services being rendered for dental surgeries?
Are oral surgery services being provided in the office?
Is the member receiving Gender Affirming services?

To submit a prior authorization Login HereExternal Link.

 

2023 30 Most Frequently Submitted CPT Codes (PDF)

2024 30 Most Frequently Submitted CPT Codes (PDF)