Ambetter Prior Authorization
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 all services rendered by an Optician, Ophthalmologist or Optometrist need to be verified by Envolve Vision Services.
Dental services need to be verified by Envolve Dental.
Musculoskeletal Services need to be verified by Turning Point.
Complex imaging, MRA, MRI, PET, and CT Scans, as well as Speech, Occupational and Physical Therapy need to be verified by NIA. For Chiropractic providers, no authorization is required for therapy services.
Services provided by out-of-network providers are not covered by the plan. 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?
|Types of Services||YES||NO|
|Are the services being performed or ordered by a non-participating provider?|
|Is the member being admitted to an inpatient facility?|
|Are anesthesia services being rendered for pain management or dental surgeries?|
|Is the member receiving hospice services?|
|Are services being rendered in the home, excluding Sleep Studies, DME, Medical Equipment Supplies, Orthotics and Prosthetics?|
To access Superior clinical and payment policies, visit Clinical & Payment Polices.