Skip to Main Content

Medicaid Pre-Auth

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 (pdf). If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

ATTENTION: 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.

 

Additional information on Medicaid Exceptions (form) (PDF).

Prior Authorization at a Glance

Prior Authorization is NOT Required

The following services do NOT require prior authorization:

  • Services rendered in an emergency room or urgent care center
  • Services rendered by a public health or welfare agency
  • Family planning services billed with a contraceptive management diagnosis

Prior Authorization IS Required

The following services REQUIRE prior authorization:

  • Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
  • Admission of a member to an inpatient facility
  • Hospice services
  • Anesthesia services for pain management or dental procedures.
  • Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
  • Services rendered by a chiropractor

Prior Authorization Check

To submit a prior authorization Login Here

SERVICES BY VENDOR:

CENTENE SERVICES:

TURNING POINT: (ph: 1-855-777-7940,  fax: 1-573-469-4352)

  • Ear, Nose & Throat
  • Cardiac Services

EVOLENT:

  • Complex Imaging, CT scan, PET, MRA, MRI and high tech radiology procedures
  • Musculoskeletal Services
  • Outpatient Physical, Occupational and Speech Therapy Services

HOME STATE HEALTH: 1-855-694-HOME (4663), TTY 711

  • Behavior Health/Substance Abuse - The Home State Health Behavioral Health UM and Customer Service staff can be reached directly at 1-866-864-1459
  • Sleep Study Services 

MO HEALTHNET:

  • Biopharmacy
  • Vaccines

        ***

» 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.*

CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries

In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.

Reports:

The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.