Medicaid and CHIP 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.
Dental services need to be verified by DentaQuest.
Musculoskeletal, Ear, Nose and Throat (ENT) Surgeries, Sleep Study Management and Cardiac Surgeries Need to be Verified by TurningPoint.
*Please note, Incontinence Supplies ordered through the preferred DME provider do not require prior authorization.
Would this be for Family Planning services billed with a contraceptive management diagnosis OR Is this service for a Star Kids or Star Health Member for school based telemedicine?
|Types of Services||YES||NO|
|Are services being provided by a non-participating provider?|
|Is the member being admitted to an inpatient facility?|
|Is the member receiving oral surgery services?|
|Is the member receiving plastic and reconstructive surgeon services?|
To supplement the Prior Authorization Prescreen Tool, providers may access Prior Authorization Requirements for Medicaid and CHIP Services (PDF), to verify prior authorization requirements for all Medicaid and CHIP services, and confirm the effective date of new prior authorization requirements implemented on or after September 1, 2019.
Clinical Documentation Requirements for Health Care Services that Require Authorization (PDF)
This listing provides the clinical documentation required to be submitted with requests for medical necessity review and approval through Superior’s contracted Utilization Review Agents (URA).
To access Superior clinical and payment policies, visit Superior's Clinical & Payment Policies webpage.