Prior Authorization

Please note, failure to obtain authorization may result in administrative claim denials. Home State providers are contractually prohibited from holding any member financially liable for any service administratively denied by Home State for the failure of the provider to obtain timely authorization.

No Referrals Needed
As the Medical Home, PCPs should coordinate all healthcare services for Home State members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.

Prior Authorizations
Some services require prior authorization from Home State in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified. Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

Prior Authorization Fax Numbers:

Inpatient Services/Admissions/Fact Sheets/Census 1-866-390-2739
Outpatient Services 1-855-286-1811
Concurrent Review — Clinicals 1-866-390-3139
OT/PT/ST Outpatient Services 1-855-254-1798
Behavioral Health Services 1-866-694-3649
 

Or login to submit a prior authorization.

Please visit our Tools & Resources section under “Forms” for prior authorization fax forms.
Behavioral Health Services are authorized by Cenpatico at www.Cenpatico.com.
High Tech Imaging Services (CT, MRI, PET) are authorized by National Imaging Associates at http://www1.radmd.com/.

  • Emergency room and post stabilization services never require prior authorization.
  • All services in the home require authorization.
  • DME purchases costing $500 or more or rental of $250 more require prior authorization

Home State’s Medical Management department hours of operation are Monday through Friday from 8:00 a.m. to 5:00 p.m., EST (excluding holidays). After normal business hours, NurseWise staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date. We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.