Pre-Auth Check Tool | Ambetter from Home State Health

 

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. 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.


ATTENTION: Prior Authorization Requests should be submitted via our secure provider web portal.  To submit a prior authorization Login Here. Copies of all supporting clinical information are required for prior authorizations. Lack of clinical information may result in delayed determination or an adverse determination.

 

The following services (identifiable by procedure code search) need to be verified by Evolent: 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); Musculoskeletal services for the spine, shoulder, hip, and knee. 

 

Oncology/supportive drugs for members age 18 and older need to be verified by New Century Health.

 

Cardiac services need to be verified by TurningPoint.  Please contact TurningPoint at 1-855-777-7940 or by fax at 1-573-469-4352.

 

Pre-Auth Training Resource (PDF)

 

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 (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 REASSIGMENT SERVICES?

To submit a prior authorization Login Here.