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
Contact the member’s designated dental MCO for member dental services
Cardiac Imaging, Complex imaging, CT, PET, MRA, MRI, High Tech Radiology, and Musculoskeletal procedures need to be authorized by Evolent.
ENT and Interventional Cardiology Services need to be verified by Turning Point.
Home Health (Infusion) services need to be verified by Sunshine Health. DME/home infusion form (PDF)
MMA, SMI, and Child Welfare Therapy requests (PT, OT, ST) at Outpatient free standing facilities are managed through HN1. HN1 does not manage members aged 0-2, PPEC, EIS, or Outpatient hospital. HN1 can be reached at 1-888-550-8800, or visit ATA of Florida.
In Region 1 only, behavioral health services are authorized by Access Behavioral Health.
DME Services need to authorized by Coastal Care Services.
Would this be for services rendered in the Emergency Room or Urgent Care Center; or are services being rendered by Public Health or Welfare Agency; or are these Family Planning services billed with a contraceptive management diagnosis?
|Types of Services
|Is the member being admitted to an inpatient facility?
|Is the member receiving hospice services?
|Are anesthesia services being rendered for pain management or dental procedures?
|Are services other than DME, orthotics, prosthetics, supplies, and therapeutic injections being rendered in the home?
|Are services being rendered by a non-participating podiatrist?