Pre-Auth Needed? | Ambetter de Peach State Health Plan

 

Pre-Auth Needed?

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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.
 

Behavioral Health/Substance Abuse, Home Health and Durable Medical Equipment services need to be verified by Ambetter from Peach State Health Plan.
 

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; Pain management and spinal cord stimulator services. 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) services need to be verified by TurningPoint.
 

Post-acute facility (SNF, IRF, and LTAC) services need to be verified by CareCentrix:  Fax 877-250-5290.  Swing Bed services should be authorized by Ambetter from Peach State Health Plan.


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 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.