Please note:

Please be advised that we are currently experiencing longer than normal hold times when calling our Medical Management Department at 1-833-863-1310. The preferred methods for submitting authorizations are through the Secure Provider Portal at provider.ambetterofnorthcarolina.com or by using Availity Essentials. Once you submit your Prior Authorization request, the quickest method to check authorization status is through the Secure Provider Portal.

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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.  Claim payment depends on member 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 Centene Vision Services.

Dental services need to be verified by Centene Dental Services.

Cardiac services need to be verified by TurningPoint.

Behavioral Health/Substance Abuse services need to be verified by Ambetter of North Carolina.

The following services need to be verified by Evolent: Speech, occupational & physical therapy; Complex Imaging, MRA, MRI, PET & CT scans; Pain Management.

The following services need to be verified by Evolent: Medical and Radiation Oncology Biopharmacy drugs.

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.


Services provided by Out-of-Network providers are not covered by the plan, without prior authorization. Join Our Network.

NOTE: Services related to an authorization denial will result in denial of all associated claims.

Are Services being performed in the Emergency Department?

Types of Services YES NO
Are the 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?

To submit a prior authorization Login Here.