Medicare Pre-Auth
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
Complex imaging, MRA, MRI, PET, and CT scans and Cardiac need to be verified by NIA
Effective 5/1/2024 Cardiac Surgical services need to be verified by TurningPoint.
Medical Oncology, Hematology, Urology, Surgical Oncology, Neurological Oncology, Gynecologic Oncology, and Radiation Oncology will submit their chemotherapy prior authorizations through New Century Health (Effective 11/1/23).
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 are the services for dialysis or Hospice?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Are services other than lab, radiology, domicilliary visits or DME being rendered in the home? | ||
| Are anesthesia services being rendered for pain management or services in the office rendered by a non-participating provider? | ||
| Is the member receiving gender reassignment services? | ||
| Is this an HMO Out of Network service request? |