Pre-Auth Needed? | Ambetter de Sunshine Health

 

Pre-Auth Needed?

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DISCLAIMER: Your current browser's security settings does not allow the use of this tool. This tool requires the use of Internet Explorer 10 or Later. If you are currently using Internet Explorer as your browser and you see this message, you should try to update it or use another browser like Google Chrome or Firefox.
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.

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;   Chiropractic specialty providers are NOT managed by Evolent.   

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

Cardiac and Ear, Nose and Throat (ENT) procedures need to be verified by TurningPoint.

Behavioral Health/Substance Abuse services need to be verified by Sunshine Health.

Drug authorizations need to be verified by Envolve Pharmacy Solutions.  For assistance call 866-399-0928.

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

Discharge ONLY DME/ Home Health Fax 833-422-1462

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, 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 Affirming services?

To submit a prior authorization Login Here.