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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

For Complex Imaging MRA, MRI, PET, and CT scan authorizations - click here
to access Evolent

For PT/OT/ST, Cardiac, MSK, IPM Pain Management authorizations - click here
to access Evolent

For Medical Oncology, Radiation Oncology, Cardiology authorizations - click
here to access Evolent (effective 6/1/2024)

 

Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network.

Are Services being performed in the Emergency Department or Urgent Care Center or Family Planning services billed with a Contraceptive Management diagnosis?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Is the member receiving hospice services?
Is the member receiving chiropractic services?

To submit a prior authorization Login Here.

Last Updated: 05/10/2024