Medicare Pre-Auth
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 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 MTBA.
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? |
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 Professional Health Care Network (PHCN)
- Log into PHCN portal at https://professionalcares.com/
- Call PHCN at 602-395-5100
- Fax to 480-359-3834