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Pre-Auth Check Tool | Ambetter from SilverSummit HealthPlan
Pre-Auth Needed?
/content/ambetter-nv/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. 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.
Behavioral Health services are handled by Silver Summit Health Plan.
Musculoskeletal Surgical Services need to be verified by TurningPoint. Effective for dates of service 05/01/2024 forward, Cardiac Surgical Services also need to be verified by TurningPoint.
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 11/1/2023, identified Oncology Biopharmacy drugs need to be verified by New Century Health.
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 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? |