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 need to be verified by Envolve Vision
Dental services need to be verified by Dental Health and Wellness
If performed in 2014, Dental services need to be verified by MCNA, Managed Care of North America
Complex imaging, CT, PET, MRA, MRI, and high tech radiology procedures need to be authorized by NIA
Musculoskeletal Services need to be verified by Turning Point
Home health services need to be verified by Sunshine Health. DME/home infusion form (PDF)
Non-participating providers must submit Prior Authorization for all services
For non-participating providers, Join Our Network
Would this be for services rendered in the Emergency Room or Urgent Care Center; or are services being rendered by Public Health or Welfare Agency; or are these Family Planning services billed with a contraceptive management diagnosis?
|Types of Services||YES||NO|
|Is the member being admitted to an inpatient facility?|
|Is the member having an observation stay?|
|Is the member receiving hospice services?|
|Are anesthesia services being rendered for pain management or dental procedures?|
|Are services other than DME, orthotics, prosthetics, supplies, and therapeutic injections being rendered in the home?|