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. Payment may be denied in accordance with Plan’s policies and procedures and applicable law. 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.
ATTENTION: Effective January 1, 2021 Prior Authorization Requests should be submitted via our secure provider web portal. To submit a prior authorization Login Here. Copies of all supporting clinical information are required for prior authorizations. Lack of clinical information may result in delayed determination or an adverse determination.
Are services being performed in the Emergency Department, or for Emergent Transportation?
|Types of Services||YES||NO|
|ARE 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?|
|IS THE MEMBER RECEIVING GENDER REASSIGMENT SERVICES?|
|ARE SERVICE BEING RENDERED IN THE HOME EXCLUDING SLEEP STUDIES, DME, MEDICAL EQUIPMENT SUPPLIES, ORTHOTICS AND PROSTHETICS?|
» Outpatient Physical, Occupational and Speech Therapy Services need to be verified by NIA.
» High Tech Imaging services are handled by NIA.
» Behavioral Health services are handled by Home State Health.
» Musculoskeletal or Cardiac Services need to be verified by Turning Point
» Oncology/supportive drugs for members age 18 and older need to be verified by New Century Health
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.