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Pre-Auth Check Tool | Ambetter from Home State Health
Pre-Auth Needed?
/content/ambetter-mo/en_us/provider-resources/manuals-and-forms/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. Claim payment depends on member eligibility, covered benefits, provider contracts, correct coding and billing practices. 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.
ATTENTION: Prior Authorization Requests should be submitted via our secure provider web portal. To submit a prior authorization Login Here. Copies of all supporting clinical information are required for prior authorizations. Lack of clinical information may result in delayed determination or an adverse determination.
Vision services need to be verified by Centene Vision Services.
Dental services need to be verified by Centene Dental Services.
The following services need to be verified by Evolent: Speech, occupational & physical therapy; Complex Imaging, MRA, MRI, PET & CT scans; Musculoskeletal services for shoulder, hip, spine and knee surgery.
The following services need to be verified by Evolent: Medical Oncology / Biopharmacy services for members age 18 and older.
NOTE: Services identified as administered by a Vendor may be specific to certain provider specialties, locations, procedure and diagnosis codes. For example, Physical Therapy services rendered by Chiropractic specialty providers or via Telehealth locations are NOT managed by Evolent. Any service rejected by the Vendor as outside of their scope of managed services, please enter a request to establish Health Plan authorization requirements.
Cardiac services need to be verified by TurningPoint. Please contact TurningPoint at 1-855-777-7940 or by fax at 1-573-469-4352.
Ambetter Health Solutions PPO members receive benefit coverage for In and Out-of-Network providers. For all other Ambetter EPO/HMO members, services provided by Out-of-Network providers are not covered by the plan, without prior authorization. Join our Network.
Are Services being performed in the Emergency Department?
| Types of Services | YES | NO |
|---|---|---|
| For NON-PPO Members only: ARE SERVICES BEING PERFORMED OR ORDERED BY A NON-PARTICIPATING PROVIDER (PROFESSIONALS/FACILITIES)? | ||
| IS THE MEMBER BEING ADMITTED TO AN INPATIENT FACILITY? | ||
| ARE ANESTHESIA SERVICES BEING RENDERED FOR DENTAL SURGERIES? | ||
| ARE ORAL SURGERY SERVICES BEING PROVIDED IN THE OFFICE? | ||
| IS THE MEMBER RECEIVING GENDER AFFIRMING SERVICES? |