OHP Pre-Auth
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 New Century Health
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.
Are services being performed in the Emergency Department or Urgent Care Center, or are services for dialysis? (IF YES THEN NO AUTH REQUIRED)
| Types of Services | YES | NO |
|---|---|---|
| Is the provider non-participating in the Trillium OHP Provider Network? | ||
| Is the member being admitted to an inpatient facility? | ||
| Are services other than DME, Medical Equipment Supplies, Orthotics/Prosthetics, Doula Services or Home Infusion S Codes being rendered in the home? | ||
| Are anesthesia services being requested for pain management, dental surgery, or services in the office rendered by a non-participating provider? |