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Medicare Pre-Auth

Scheduled Maintenance

Please Note: The Authorization Tool will be under maintenance Thursday, July 29 at 6:00 p.m. Central Time to 9:00 p.m. Central Time.  Certain functions of the tool may not work properly during this time. We apologize for the inconvenience. Thank you for your patience.

Attention Providers: For authorization requests for date of service 1/1/18 and forward, utilize this tool to verify prior authorization requirements. To submit prior authorization by fax, please send to 877-808-9362.

Prior Authorization Changes - Effective June 1, 2021

Prior authorization (PA) requirement changes related to COVID Treatment and Telehealth services have been updated. We are updating our Pre-Auth tool. Please review this Provider Communication for more information.

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

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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.

Vision Services are managed by Envolve Vision, administered by EyeMed.

Dental Services for Medicare are administered by Envolve Dental.

High Tech Imaging services are handled by NIA.

Musculoskeletal Services need to be verified by Turning Point.

Chiropractic services are handled by ASH.

Transportation services are handled by Veyo.

Oncology/supportive drugs are handled by New Century Health.

 

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

 

Are services being performed in the Emergency Department, Urgent Care, Emergent Transportation, Dialysis, or for Hospice?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Is the member having gender reassignment services?
Are anesthesia services being required for pain management or services in the office rendered by a non-participating provider?
Are services being rendered in an unspecified location/place of service (other)?

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 Professional Health Care Network (PHCN)