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.
Please refer to the Prior Auth Quick Reference Guide (PDF) for questions.
Our Pre-Auth tool is not reflecting accurate language at this time and is in the process of being updated for the following codes:
Q4186 is a covered benefit and require a prior authorization for all providers.
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.
There are no annual limits for Physical, Speech and Occupational Therapy evaluations for Coordinated Care members. Please check the code using our tool below to verify if authorization is required.
The following medications are not covered benefits under the Coordinated Care Health Plan:
- ATA-129 (tabelecleucel®)
- AVXS-101 (Zolgensma®)
- BMN 270 (valoctocogene roxaparvovec)
- Elapegademase-lvlr (RevcoviTM)
- Hemophiliac Products – Anti-hemophiliac blood factors VII, VIII, and IX, anti-inhibitor, and biological products FDA approved with an indication for use in treatment of hemophilia or von Willebrand disease when distributed for administration in the member’s home or other outpatient setting.
- Immune modulators and anti-viral medications to treat Hepatitis C. This exclusion does not apply to any other contracted service related to the diagnosis or treatment of Hepatitis C.
- KTE-X19 (valoctocogene roxaparvovec)
- Lenti-D TM
- NS-065 (viltolarsen)
- Pegvaliase-pqpz (PalynziqTM)
- Reblozyl® (luspatercept)
- RG7916 (risdiplam)
- SRP-4045 (casimersen)
- Tisagenlecleucel-t (KymriahTM)
- UX007 (triheptanoin)
- Vyondys 53 (GolodirsenTM)
- Zynteglo (lentiglobin)
Vision Services need to be verified by Envolve Vision.
Dental Services need to be verified by DSHS.
Complex imaging, MRA, MRI, PET, and CT scans need to be verified by NIA.
Musculoskeletal Services need to be verified by Turning Point
Behavioral Health/Substance Abuse requests can be submitted using our web portal or by fax, using an OTR form (PDF).
For non-participating providers, Join Our Network.
Please note: we will need medical records supporting your request for services requiring a medical necessity review. Note for Non-Urgent Preservice Decisions the plan has 5-14 days to make a determination. For Urgent Preservice Decisions the plan has 2 calendar days to make a determination. For Standard Psychiatric Inpatient Services the plan has 12 hours of the receipt of the request to make a determination. For Urgent Concurrent and Post Stabilization Decisions the plan has 1 calendar day to make a determination.
Are services being performed in the emergency department or urgent care center or are these family planning services billed with a contraceptive management diagnosis?
|Types of Services||YES||NO|
|Is the member being admitted to an inpatient facility?|
|Are professional services being rendered in the home? (Behavioral Health services shall be offered at the location preferred by the Medicaid-enrolled individual, as long as it is clinically necessary, and provided by or under the supervision of a Mental Health Professional)|
|Is anesthesia being rendered for pain management or dental surgery?|
|Are oral surgeon services being rendered in office?|