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Pre-Auth Check Tool | Ambetter from PA Health & Wellness
Pre-Auth Needed?
/content/ambetter-pa/en_us/provider-resources/pre-auth-check
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.
Behavioral Health/Substance Abuse services need to be verified by Ambetter from Pennsylvania Health and Wellness.
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; Chiropractic specialty providers are NOT managed by Evolent.
The following services need to be verified by EvolentExternal Link: Cardiac surgical services for members ages 18 years and older.
Post-acute facility (SNF, IRF, and LTAC) services need to be verified by CareCentrix: Fax 877-250-5290; Telephone 833-592-1081; OR, requests may be submitted via the Ambetter portal and the Plan will fax the request to CareCentrix.
Services provided by Out-of-Network providers are not covered by the plan, without prior authorization. Join Our NetworkExternal Link
NOTE: Services related to an authorization denial will result in denial of all associated claims.
Are Services being performed in the Emergency Department?
| Types of Services | YES | NO |
|---|---|---|
| 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? |