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Medicaid Pre-Auth

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DISCLAIMER:

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.

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 Urgent Care Center, Public Health or Public Welfare Agency, or Family Planning services billed with a contraceptive management diagnosis?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are anesthesia services being rendered for pain management?
Are services for a facility billing with Dental Diagnosis?
Are oral surgery services being provided in the office?
Are services, other than DME, orthotics, prosthetics, and supplies, being rendered in the home?

 

 

» Routine Vision Services need to be verified by Envolve Vision.

» Dental Services need to be verified by Envolve Dental.

» Biopharmacy and Vaccines are carved out to MO HealthNet.

» Behavior Health/Substance Abuse prior authorization request and questions, please call 1-866-864-1459.

»  Outpatient Physical, Occupational and Speech Therapy Services for <21 years of age, need to be verified by NIA

»  Alternative Therapy for Chronic Pain > age 21, need to be verified by Home State Health

»  Outpatient Physical, Occupational and Speech Therapy Services for Pregnant Women > age 21, need to be verified by Home State Health

» Cardiac Services need to be verified by Turning Point

» The following services need to be verified by Evolent (formerly NIA)

Complex Imaging, CT scan, PET, MRA, MRI and high tech radiology procedures and Musculoskeletal Services

» Ear, Nose & Throat (ENT) Surgeries and Sleep Study services need to be verified by TurningPoint. 

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» Non-participating providers must submit Prior Authorization for all services.

» For non-participating providers, Join Our Network.

 

Important Information for Out of Network Providers (PDF) 

 

*There may be age restrictions for DME and therapy services. It is important that you check the provider manual located on the MO Health Net website to confirm coverage. Prior authorization does not guarantee payment.*