Pre-Auth Check | Ambetter from MHS Indiana

 

Pre-Auth Needed?

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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..

Vision services need to be verified by Envolve Vision

The following services (identifiable by procedure code search) need to be verified by Evolent:  Complex Imaging, MRA, MRI, PET, and CT scans; Pain Management and Spinal Cord Stimulators;  Speech, Occupational and Physical Therapy (excluding chiropractor specialty providers – no authorization required); Effective for dates of service 1/1/2024 forward, Musculoskeletal services for the spine, shoulder, hip and knee.

Dental services need to be verified by Envolve Dental

Behavioral Health/Substance Abuse need to be verified by Indiana Managed Health

Cardiac procedures need to be verified by Evolent. Musculoskeletal services for DOS will be verified by Evolent.

For Chiropractic providers, no authorization is required.

Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix ; Fax 877-250-5290.

Services provided by Out-of-Network providers are not covered by the plan. Join Our Network

Note: Services related to an authorization denial will result in denial of all associated claims.

 

Are Services being performed in the Emergency Department?

Types of Services YES NO
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?