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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
Vision Services need to be verified by Envolve Vision.
Dental Services need to be verified by Envolve Dental.
The following services (identifiable by procedure code search) need to be verified by Evolent: Complex Imaging, MRA, MRI, PET, and CT scans; Left Heart Catheterization; Implantable services; Speech, Occupational and Physical Therapy services. Effective for dates of service 3/1/2024 forward: Pain Management services; Spinal Cord Stimulators; Musculoskeletal services for the spine, shoulder, hip, and knee.
Oncology Biopharmacy and Radiation Oncology drugs need to be verified by New Century Health.
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
|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?