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Pre-Auth Needed? | Ambetter de MHS
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.
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.
- Last Updated: 05/19/2026
- Next Scheduled Update: Q3 2026
Ambetter Prior Auth Statistics January 01, 2026 - March 31, 2026
Medical | Total | Percent | Total | |
|---|---|---|---|---|
Prior Authorization Requests Received | 3,757 | Medical Appeal Requests Received | 941 | |
Fully Approved | 2,989 | 79.56% | Overturned | 386 |
Adverse Determinations | 674 | 17.94% | Upheld | 550 |
Partial Approvals | 94 | 2.50% | Partial Approval | 5 |
Average time between submission and response | 2.19 DAYS | 7.4 DAYS | ||
Behavioral | Total | Percent | Total | |
|---|---|---|---|---|
Prior Authorization Requests Received | 568 | Behavioral Appeal Requests Received | 59 | |
Fully Approved | 414 | 72.89% | Overturned | 22 |
Adverse Determinations | 63 | 11.09% | Upheld | 25 |
Partial Approvals | 91 | 16.02% | Partial Approval | 12 |
Average time between submission and response | 3.73 DAYS | 9.35 DAYS | ||
Pharmacy | Total | Percent | Total | |
|---|---|---|---|---|
Prior Authorization Requests Received | 14,396 | Pharmacy Appeal Requests Received | 482 | |
Fully Approved | 8,876 | 61.66% | Overturned | 171 |
Adverse Determinations | 5,511 | 38.28% | Upheld | 311 |
Partial Approvals | 9 | 0.06% | Partial Approval | 0 |
Average time between submission and response | 0.52 DAYS | 15.61 DAYS | ||
Top 10 reasons for adverse determinations
Medical | Behavioral | Pharmacy | |
|---|---|---|---|
Medical Necessity | Medical Necessity | Medical Necessity | |
Top 10 CPT Codes submitted
Medical | Indication Offered | Reason for denial | |
|---|---|---|---|
95811 | OBSTRUCTIVE SLEEP APNEA | Medical Necessity | |
G0480 | OPIOID DEPENDENCE UNCOMPLICATED | Medical Necessity | |
95810 | OBSTRUCTIVE SLEEP APNEA | Medical Necessity | |
E0601 | OBSTRUCTIVE SLEEP APNEA | Medical Necessity | |
G0481 | CHRONIC PAIN SYNDROME | Medical Necessity | |
99221 | CHEST PAIN UNSPECIFIED | Medical Necessity | |
0340U | MALIGNANT NEOPLASM OF RECTUM | Medical Necessity | |
A7030 | OBSTRUCTIVE SLEEP APNEA | Medical Necessity | |
A7035 | OBSTRUCTIVE SLEEP APNEA | Medical Necessity | |
81432 | FAMILY HX MALIG NEOPLASM OF BREAST | Medical Necessity | |
Top 10 CPT Codes submitted
Behavioral | Indication Offered | Reason for denial | |
|---|---|---|---|
97151 | AUTISTIC DISORDER | Medical Necessity | |
90837 | GENERALIZED ANXIETY DISORDER | Medical Necessity | |
97152 | AUTISTIC DISORDER | Medical Necessity | |
H0010 | OPIOID DEPENDENCE UNCOMPLICATED | Medical Necessity | |
99212 | MAJ DEPRESS RECURR SEV W/O PSYCH | Medical Necessity | |
97156 | AUTISTIC DISORDER | Medical Necessity | |
97155 | AUTISTIC DISORDER | Medical Necessity | |
97153 | AUTISTIC DISORDER | Medical Necessity | |
S9480 | MAJ DEPRESS RECURR SEV W/O PSYCH | Medical Necessity | |
96130 | REACTION TO SEVERE STRESS UNS | Medical Necessity | |
Top 10 CPT of J-Codes submitted
Pharmacy | Indication Offered | Reason for denial | |
|---|---|---|---|
J7323 | BILATERAL PRIM OSTEOARTHRITIS KNEE | Medical Necessity | |
J3489 | AGE-REL OSTEOPOR W/O CURR PATH FX | Medical Necessity | |
J0585 | CHR MIGRAINE W/O AURA INTRCT W/O SM | Medical Necessity | |
Q0138 | IRON DEFICIENCY ANEMIA UNSPECIFIED | Medical Necessity | |
J7324 | UNI PRIM OSTEOARTHRITIS RT KNEE | Medical Necessity | |
J7327 | BILATERAL PRIM OSTEOARTHRITIS KNEE | Medical Necessity | |
Q5125 | MALIGNANT NEOPLASM CORPUS UTERI UNS | Medical Necessity | |
J7318 | UNI PRIM OSTEOARTHRITIS LT KNEE | Medical Necessity | |
J1306 | MIXED HYPERLIPIDEMIA | Medical Necessity | |
J3380 | ULCERATIVE COLITIS UNS W/O COMP | Medical Necessity | |