Pre-Auth Check Tool | Ambetter from NH Healthy Families

 

Pre-Auth Needed?

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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. 

Routine Vision Services are not covered by this Health Plan.  Medical Services provided by an Optometrist, Optician or Opthalmologist need to be verified by Envolve Vision.

Behavioral Health/Subtance Abuse services need to be verified by NH Healthy Families.

Oncology/supportive drugs and Radiation Oncology requests need to be verified by Evolent Specialty Services (ESS).

The following services (identifiable by procedure code search) need to be verified by Evolent: Complex Imaging, MRA, MRI, PET, and CT scans; Left Heart Catheterization & Implantable services; Pain Management;  Spinal Cord Stimulators and Musculoskeletal services for the spine, shoulder, hip and knee; Speech, Occupational and Physical Therapy (home health agencies with episodic care agreements, these are processed through the plan, and excluding chiropractor specialty providers – no authorization required).

Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix ; Fax 877-250-5290.
 

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?

Types of Services YES NO
Are the services for EPO members 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?

To submit a prior authorization Login Here.