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 provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
Vision services, including all services rendered by an Optician, Ophthalmologist or Optometrist need to be verified by Envolve Vision
Dental services need to be verified by Envolve Dental
Behavioral Health/Substance Abuse need to be verified by Cenpatico
Complex imaging, MRA, MRI, PET, and CT Scans need to be verified by NIA
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network.
Basic laboratory chemistries and basic radiology do NOT require prior authorization for participating or non-participating providers.
Are Services being performed in the Emergency Department or Urgent Care Center, FQHC or RHC, or Family Planning services billed with a V25 to V25.9 diagnosis?
|Types of Services||YES||NO|
|Is the member being admitted to an inpatient facility?|
|Are anesthesia services being rendered for pain management or dental surgeries?|
|Is the member receiving hospice services?|
|Are services other than DME, orthotics, prosthetics, and supplies, being rendered in the home?|