OHP Pre-Auth
DISCLAIMER: Please be sure to check line finder. 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 upon eligibility, covered benefits, provider contracts and correct coding and billing practices. For specific details, please refer to the OHP Billing Manual (PDF) 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
- Complex imaging, CT, PET, MRA, MRI, and high tech radiology procedures, and Musculoskeletal need to be authorized by Evolent. Click here to access RadMD or call 888-879-5922 for Medicaid, 800-642-2798 for Medicare.
- Oncology/supportive drugs need to be verified by Evolent
Out of Network
All Out-of-Network requests require prior authorization except emergency care, services in an urgent care facility or Acute Medical Inpatient Services unless admitted through the ER. For non-participating providers, Join Our Network.
Exceptional Needs
Requests for a service/product based on exceptional needs can be entered on the Secure Provider Portal.
Prior Authorization at a Glance
Prior Authorization is NOT Required
The following services do NOT require prior authorization:
- Services rendered in an emergency room or urgent care center
- Services rendered by a public health or welfare agency
- Family planning services billed with a contraceptive management diagnosis
Prior Authorization IS Required
The following services REQUIRE prior authorization:
- Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
- Admission of a member to an inpatient facility
- Hospice services
- Anesthesia services for pain management or dental procedures.
- Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
- Services rendered by a chiropractor
Prior Authorization Check
To submit a prior authorization Login Here