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 Medicare Advantage 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
If performed in 2014, Dental services need to be verified by MCNA, Managed Care of North America
If performed in 2015, Dental services need to be verified by Dental Health and Wellness
Home health services need to be verified by Sunshine Health [link to DME form/home fusion form]
Complex imaging, CT, PET, MRA, MRI, and high tech radiology procedures need to be authorized by NIA
All out of network requests require Prior Authorization, except emergency care and out-of-area requests.
For non-participating providers, Join Our Network
For a list of services that require prior authorization click here (link to PDF).
Are services being performed in the Emergency Department, or Urgent Care Center, or are the services for dialysis or Hospice?
|Types of Services||YES||NO|
|Is the member being admitted to an inpatient facility?|
|Are services other than lab, radiology, domiciliary visits or DME being rendered in the home?|
|Are anesthesia services being requested for pain management or dental surgery?|