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Medicare Pre-Auth

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. All new, re-sequenced and unlisted codes (miscellaneous codes) require prior authorization, regardless of place of service.

Vision Services are, administered by Premier Eye Care.

Dental Services for Medicare are administered by DentaQuest.

High Tech Imaging services are handled by Evolent.

Musculoskeletal Services need to be verified by Turning Point.

Chiropractic services are handled by ASH.

Transportation services are handled by MTM (formerly MTBA).

Oncology/supportive drugs are handled by Evolent.

All Out of Network requests require prior authorization except emergency care, out-of area urgent care or out-of-area dialysis.

Prior Authorization at a Glance

Prior Authorization is NOT Required

The following services do NOT require prior authorization:

  • Services rendered in an emergency room or urgent care center
  • Services rendered by a public health or welfare agency
  • Family planning services billed with a contraceptive management diagnosis

Prior Authorization IS Required

The following services REQUIRE prior authorization:

  • Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
  • Admission of a member to an inpatient facility
  • Hospice services
  • Anesthesia services for pain management or dental procedures.
  • Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
  • Services rendered by a chiropractor

Prior Authorization Check

To submit a prior authorization Login Here

Prior Authorization (PA) Changes

Effective June 1, 2021 - PA Requirement Changes related to COVID Treatment and Telehealth services learn more [link to communication]

Please contact Provider Services if you have questions. If you need additional help please contact your Provider Engagement Specialist.

For Home Health, please request prior authorizations through Tango Care (formerly PHCN)