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Pre-Auth Check Tool | Ambetter from PA Health & Wellness
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.
The following services (identifiable by procedure code search) need to be verified by Evolent: Complex Imaging, MRA, MRI, PET, and CT scans; Speech, Occupational and Physical Therapy services (excluding chiropractor specialty providers – no authorization required). Effective for dates of service 3/1/2024 forward, Musculoskeletal services for the spine, shoulder, hip and knee.
Behavioral Health services need to be verified by Ambetter from Pennsylvania Health and Wellness.
Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix ; Fax 877-250-5290.
Musculoskeletal Surgical services for dates of service prior to 3/1/2024 will continue to be verified by TurningPoint. Please contact Turning Point by phone at 855-909-8222 or by fax at 717-303-5072.
NOTE: Services related to an authorization denial will result in denial of all associated claims.
Are services being performed in the Emergency Department, or for Emergent Transportation?
|Types of Services
|Are the services being performed or ordered by a non-participating provider (professionals/facilities)?
|Is the member being admitted to an inpatient facility?
|Are anesthesia services being rendered for dental surgeries?
|Are oral surgery services being provided in the office?
|Is the member receiving gender reassignment services?