Ambetter Pre-Auth
For the best experience, please use the Pre-Auth tool in Chrome, Firefox, or Internet Explorer 10 and above.
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.
Our Pre-Auth tool is not reflecting accurate language at this time and is in the process of being updated for the following codes:
As of Jan. 1, 2020, B4185, B4189, B4193, B4197, B4199, B4220, B4224, B9004 require prior authorization for all providers.
As of Jan. 1, 2020, B4161, B4160, B4159, B4158, B4155, B4154, B4153, B4152, B4150, B4149, B4103, B4102 require prior authorization when billed with modifier “BO”. Otherwise, authorization is not required. BO = orally administered nutrition, not by feeding tube.
Vision services, including all services rendered by an Optician, Ophthalmologist, Or Optometrist need to be verified by Envolve Vision
Dental services need to be verified by Envolve Dental
Complex imaging, MRA, MRI, PET, and CT Scans need to be verified by NIA
Musculoskeletal Services need to be verified by Turning Point
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? | ||
| 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? |