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Medicare Pre-Auth

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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 Medicare Advantage provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

For HMO members, all Out of Network requests require prior authorization except emergency care, urgent care, or Acute Medical Inpatient Services. For non-participating providers, Join Our Network

 

***Please Note for Home Health Services*** Authorization is required per 60 day episode of care. Each episode will be reviewed for medical necessity and CMS coverage criteria.

 

Are Services for Hospice, Dialysis, or are services being performed in the Emergency Department or Urgent Care Center?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are services other than domiciliary visits, lab, radiology, DME, Medical Equipment Supplies, Orthotics or Prosthetics 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?