While every effort is made to provide the most current information on the Pre-Authorization Tool, it is important to note that this does not guarantee payment or confirm patient eligibility. For specific details, please refer to the current authorization grids and provider manual. If you are uncertain whether prior authorization is needed, please submit a request for authorization through the Provider Portal.
Vision Services need to be verified by Davis Vision.
Complex imaging, MRA, MRI, PET, and CT Scans need to be verified by Evolent (formerly NIA).
Physical, Occupational and Speech Therapy (home and outpatient) need to be authorized by Evolent.
Radiation Therapy services need to be authorized by Evolent.
Musculoskeletal Services need to be authorized by Evolent.
Cardiac Services need to be authroized by Turning Point.
Ear, Nose, and Throat Procedures need to be authorized by Turning Point.
Oncology/supportive drugs need to be verified by New Century Health.
Services provided by Non-participating providers are not covered by the plan.
All Out of Network requests require prior authorization except emergency care, out-of-area urgent care or out-of-area dialysis.
Are Services being rendered in the Emergency Room or Urgent Care?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an Inpatient Facility? | ||
| Are anesthesia services being requested for pain management, dental surgery or are services being rendered in an office setting? | ||
| Is this an HMO Out of Network service request? | ||
| Is the member admitted for Substance Use Disorder? | ||
| Will the service being requested be billed using an ‘unlisted code’? |
Click here to initiate a prior authorization through the Provider Portal OR Fax request. Fax numbers located here.