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Pre-Auth Needed? | Ambetter de MHS
Pre-Auth Needed?
For the best experience, please use the Pre-Auth tool in Chrome, Firefox, or Internet Explorer 10 and above.
/content/ambetter-in/es_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. 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; Pain management and spinal cord stimulator services.
NOTE: Services identified as administered by a Vendor may be specific to certain provider specialties, locations, procedure and diagnosis codes. For example, Physical Therapy services rendered by Chiropractic specialty providers or via Telehealth locations are NOT managed by Evolent. Any service rejected by the Vendor as outside of their scope of managed services, please enter a request to establish Health Plan authorization requirements.
Cardiac services need to be verified by TurningPoint.
Behavioral Health/Substance Abuse need to be verified by Indiana Managed Health.
Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix ; Fax 877-250-5290.
Ambetter Health Solutions PPO members receive benefit coverage for In and Out-of-Network providers. For all other Ambetter EPO/HMO members, services provided by Out-of-Network providers are not covered by the plan, without prior authorization. Join Our Network
Are Services being performed in the Emergency Department?
| Types of Services | YES | NO |
|---|---|---|
| For NON-PPO Members only: 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.
Ambetter Prior Auth Statistics 2025
| Medical/Behavioral | Total | Percent |
|---|---|---|
| Prior Authorization Requests Received | 35,160 | N/A |
| Fully Approved | 27,783 | 79.01% |
| Adverse Determinations | 7,098 | 20.19% |
| Average time between submission and response | 2.91 Days | N/A |
| Pharmacy | Total | Percent |
|---|---|---|
| Prior Authorization Requests Received | 48,942 | N/A |
| Fully Approved | 30,060 | 54.1% |
| Adverse Determinations | 18,882 | 45.9% |
| Partial Approvals | 0 | 0 |
| Average time between submission and response | 0.73 Days | N/A |
Appeals
| Appeals are inclusive of PH/BH/Vendor/Pharm data | Total |
|---|---|
| Prior Authorization Requests Received | 2,044 |
| Fully Approved | 782 |
| Adverse Determinations | 1,262 |
| Partial Approvals | 0 |
| Average time between submission and response | 22.75 Days |
Top reasons for adverse determinations
| Medical | Behavioral | Pharmacy |
|---|---|---|
| Medical Necessity Not Evident | Medical Necessity Not Evident | Medical Necessity |
| Denied by Medical Services | Admin Denial | |
| Admin Denial | Denied by Medical Services |
Top CPT Codes Requested
- 99221
- E0601
- 1002
- 59409
- 95810
- 99468
- 99231
- 59620
- 95811
- 81329
Top Medications Requested
- Ozempic
- Zepbound
- Mounjaro
- Wegovy
- Repatha
- Nurtec
- Trulicity