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Pre-Auth Needed?
/content/ambetter-ne/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. 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, including all services rendered by an Optician, Ophthalmologist or Optometrist need to be verifed by Envolve Vision.
Dental Services need to be verified by Envolve Dental.
The following services (identifiable by procedure code search) need to be verified by Evolent: Complex Imaging, MRA, MRI, PET, and CT scans; Speech, Occupational and Physical Therapy services (excluding chiropractor specialty providers – no authorization required).
Effective for dates of service 12/01/2024 and forward, Medical and Radiation Oncology Biopharmacy drug services need to be verified by New Century Health/Evolent.
Services provided by Out-of-Network providers are not covered by the plan. 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 or Urgent Care Center, or for Emergent Transportation?
| 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 reassignment services? |