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Ambetter Pre-Auth

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DISCLAIMER:

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 Opticare
Dental services need to be verified by DentaQuest
Behavioral Health/Substance Abuse need to be verified by Cenpatico
Complex imaging, MRA, MRI, PET, and CT Scans need to be verified by NIA

Note: It is the responsibility of the facility, in coordination with the rendering practitioner to ensure that an authorization has been obtained for all inpatient and selected outpatient services, except for emergency stabilization services.  All inpatient admissions require prior authorization.  To determine if a specific outpatient service requires prior authorization, utilize the Pre-Auth Needed tool below by answering a series of questions regarding the Type of Service and then entering a specific CPT code.

Any anesthesiology, pathology, radiology or hospitalist services related to a procedure or hospital stay requiring a prior authorization will be considered downstream and will not require a separate prior authorization.  However, services related to an authorization denial for an outpatient procedure or hospital stay will result in denial of all associated claims, including anesthesiology, pathology, radiology and hospitalist services.

 

Are Services being performed in the Emergency Department?

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 being rendered in the home, excluding Sleep Studies, DME, Medical Equipment Supplies, Orthotics and Prosthetics?

To submit a prior authorization Login Here.