Pre-Auth Needed? | Ambetter Insured by Celtic

 

Pre-Auth Needed?

For the best experience, please use the Pre-Auth tool in Chrome, Firefox, or Internet Explorer 10 and above. 

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. 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 any services rendered by an Optician, Optometrist or Ophthalmologist need to be verified by Envolve Vision

Dental services need to be verified by Envolve Dental

Oncology/supportive drugs for members age 18 and older need to be verified by New Century Health

The following services (identifiable by procedure code search) need to be verified by Evolent: Complex Imaging, MRA, MRI, PET, and CT scans, Pain Management, Spinal Cord Stimulators, and Musculoskeletal services for the spine, shoulder, hip and knee; Speech, Occupational and Physical Therapy (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

The following Substance Use disorder services require Notification of Admission within 1-Business Day: Residential Treatment services (ASAM Level 3.1-3.5), Partial Hospitalization Program (PHP) (ASAM Level 2.5), Intensive Outpatient Program (IOP) (ASAM Level 2.1)

Services provided by Out-of-Network providers are not covered by the plan. Join Our Network

 

Are Services being performed in the Emergency Department?

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?

To submit a prior authorization Login Here.

Tools and Resources